Method and system for generating a likelihood of cardiovascular disease, analyzing cardiovascular sound signals remotely from the location of cardiovascular sound signal acquisition, and determining time and phase information from cardiovascular sound signals

ABSTRACT

A system, method and computer executable code for generating a likelihood of cardiovascular disease from acquired cardiovascular sound signals is disclosed, where the generated likelihood of cardiovascular disease is based at least on an overlapping in time of bruit candidates in one heart cycle or in different heart cycles. Also disclosed is a system, method, and computer executable code for collecting, forwarding, and analyzing cardiovascular sound signals, where the collecting and analyzing may occur at locations that are remote from each other. Further disclosed is a system, method, and computer executable code for determining the time and phase information contained in cardiovascular sound signals, for use in analyzing those cardiovascular sound signals.

RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No.10/390,172, filed Mar. 18, 2003, now U.S. Pat. No. ______, thedisclosure of which is incorporated herein by reference in its entirety,and which claims the benefit of U.S. Provisional Application No.60/364,605, filed Mar. 18, 2002, the disclosure of which is incorporatedherein by reference in its entirety.

FIELD OF THE INVENTION

The invention relates to systems and methods for generating a likelihoodof cardiovascular disease based on acquired cardiovascular soundsignals, analyzing the cardiovascular sound signals at a location thatis remote from the location of cardiovascular sound signal acquisition,and determining time and phase information from the cardiovascular soundsignals.

BACKGROUND

Occlusions in arteries and other portions of the cardiovascular systemare often associated with various types of cardiovascular disease, suchas coronary heart disease. Many of these occlusions are believed to bethe source of turbulent flow and abnormal high frequency soundsapproximately in the 200 to 2000 Hz, usually 300 to 1800 Hz, audio band.These sounds, generically referred to as “bruits,” are known to occur atmany different time locations within a heart cycle, such as bruits thatare believed to occur during diastole when the maximum pressure from theaorta surges into the arteries. Detection of bruits can providephysicians with valuable information that can be used to assess whethera patient has cardiovascular disease, such as coronary heart disease(“CHD”). Numerous techniques have attempted to detect and analyze highfrequency signals from the cardiovascular sounds of a patient, some ofwhich use averaging, neural networks, wavelet transforms, and linearprediction analysis. However, none of these conventional techniques arebelieved to provide a reliable probability of the likelihood that apatient has cardiovascular disease.

SUMMARY OF THE INVENTION

In light of the foregoing problems associated with conventionaltechniques for detecting the presence of cardiovascular disease,generally speaking, one object of the invention is to provide a system,method, and computer executable code for generating a likelihood ofcardiovascular disease from acquired cardiovascular sound signals, wherethe generated likelihood of cardiovascular disease is based at least onan overlapping in time of bruit candidates in one heart cycle or indifferent heart cycles so as to emphasize the repetitive nature ofbruits that occur in one or multiple heart cycle signals. Another objectof the invention is to provide a system, method, and computer executablecode for collecting, forwarding, and analyzing cardiovascular soundsignals, where the collecting and analyzing may occur at locations thatare remote from each other. Still another object of the invention is toprovide a system, method, and computer executable code for determiningthe time and phase information contained in cardiovascular soundsignals, for use in analyzing those cardiovascular sound signals.

Other objects, advantages and features associated with the inventionwill become more readily apparent to those skilled in the art from thefollowing detailed description. As will be realized, the invention iscapable of other and different embodiments, and its several details arecapable of modification in various obvious aspects, all withoutdeparting from the invention. Accordingly, the drawings and thedescription are to be regarded as illustrative in nature, and notlimitative.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a system for acquiring and analyzing cardiovascular soundsignals in accordance with one embodiment of the invention.

FIG. 2 depicts one embodiment of acquired cardiovascular sound signalsand acquired noise sound signals.

FIG. 3 is a partial view of the nine locations where cardiovascularsound signals are acquired in accordance with one embodiment of theinvention.

FIG. 4 is a flow chart that depicts the overall process by whichcardiovascular sound signals are processed to generate a probabilityindicator indicative of the likelihood that a patient has cardiovasculardisease, such as coronary heart disease (CHD), according to oneembodiment of the invention.

FIG. 5 is a flow chart showing the steps involved in identifying commonreferences in the acquired cardiovascular sound signals of a patient,according to an embodiment of the invention.

FIG. 6 is a flow chart with further detail on a method for preparing theacquired cardiovascular sound signals, according to an embodiment of theinvention.

FIG. 7 is a flow chart showing the steps involved in determining a startpoint of each heart cycle signal within the acquired cardiovascularsound signals, according to an embodiment of the invention.

FIG. 8 is a flow chart showing the steps in generating smoothedcardiovascular sound signals, according to an embodiment of theinvention.

FIG. 9 illustrates smoothed cardiovascular sound signals of one heartwaveform.

FIG. 10 depicts a portion of the smoothed cardiovascular sound signalsof FIG. 9.

FIG. 11 depicts the autocorrelation peaks that result from convolvingthe smoothed cardiovascular sound signals with itself.

FIG. 12 is a flow chart depicting further detail on the process ofgenerating a beat duration estimate, according to an embodiment of theinvention.

FIG. 13 is a flow chart depicting further detail on the process ofidentifying any possible third peaks, according to an embodiment of theinvention.

FIG. 14 is a flow chart depicting further detail on the process ofgenerating a math model envelope, according to an embodiment of theinvention.

FIG. 15 is a flow chart depicting continued further detail on theprocess of generating a math model envelope, according to an embodimentof the invention.

FIG. 16 is a flow chart depicting continued further detail on theprocess of generating a math model envelope, according to an embodimentof the invention.

FIG. 17 is a flow chart depicting continued further detail on theprocess of generating a math model envelope, according to an embodimentof the invention.

FIG. 18 depicts a math model envelope, calculated in accordance with anembodiment of the invention.

FIG. 19 is a flow chart depicting further details of the process ofgenerating a bootstrap filter envelope, in accordance with an embodimentof the invention.

FIG. 20 depicts a signal consisting of a set of leveled peaks thatresult from correlating a math model envelope against the smoothed heartsignals, and then dividing by a set of automatic gain control values.

FIG. 21 illustrates a bootstrap filter that results from averagingmultiple heart cycles signals.

FIG. 22 depicts a signal consisting of a set of peaks that result fromconvolving the bootstrap filter with the filtered cardiovascular soundsignals.

FIG. 23 is a flow chart depicting the extraction of the apparent startpoints of each heart cycle signal.

FIG. 24 is a flow chart depicting the generation of a table of startpoints of heart cycle signals that are greater than a predefinedthreshold.

FIG. 25 is a flow chart depicting the calculation of a parsing score.

FIG. 26 is a flow chart depicting evaluation of peaks in the startpoints table.

FIG. 27 continues the flow chart of FIG. 26.

FIG. 28 is a flow chart depicting a search process for better fittingpeaks.

FIG. 29 continues the flow chart of FIG. 28.

FIG. 30 continues the flow chart of FIG. 27.

FIG. 31 continues the flow chart of FIG. 30.

FIG. 32 is a flow chart depicting a Vernier tuning process.

FIG. 33 is a sequence of signals showing various stages of processingsignals

FIG. 34 is a flow chart depicting the process of determining a startpoint or end point of one or more phases of each heart cycle signal.

FIG. 35 is a flow chart depicting the calculation of an averageenvelope.

FIG. 36 is a flow chart depicting the calculation of a phase window.

FIG. 37 is a flow chart depicting the computation of the expected peaklocations.

FIG. 38 is a flow chart depicting the determination of the actual peaklocations.

FIG. 39 is a flow chart depicting the determination of the valleysbetween the peak locations determined in the flow chart of FIG. 38.

FIG. 40 is a flow chart depicting assignment of the S1 through S4 phaseintervals.

FIG. 41 is a flow chart depicting the determination of the S1 regionindices.

FIG. 42 is a flow chart depicting the determination of the S2 regionindices.

FIG. 43 is a flow chart depicting the creation of an array of locationscorresponding to the start and end indices of each of the actual S1through S4 pulses.

FIG. 44 is a flow chart depicting the determination of a pulse countthat meets a set of threshold parameters.

FIG. 45 is a flow chart depicting calculation of statistics of the S1through S4 pulses.

FIG. 46 is a filtered heart audio signal showing enhanced S1 and S2pulses.

FIG. 47 is a signal representing the parsing process that identifies theS1 and S2 intervals of the heart cycle signals.

FIG. 48 shows a graphical representation of a phase window and an arrayof S1 through S4 indices.

FIG. 49 shows a portion of a pulse array and a portion of a pulsestatistics array.

FIG. 50 contains a signal that contains bruits, along with amagnification of those bruits.

FIG. 51 is a flow chart depicting the process of identifying bruitcandidates.

FIG. 52 is a flow chart depicting the process of detecting bruitcandidates in each heart cycle signal.

FIG. 53 is a flow chart depicting the calculation of skew normalizationfactors.

FIG. 54 is a flow chart depicting the creation of a table of spectralamplitude ratios.

FIG. 55 is a flow chart depicting the spectral data calculation process.

FIG. 56 is a flow chart depicting the spectral averaging process.

FIG. 57 is a flow chart depicting further details of the spectralaveraging process.

FIG. 58 is a flow chart depicting the power calculation process.

FIG. 59 is a flow chart depicting the information collection process onall bruit candidates.

FIG. 60 is a flow chart depicting the process for scanning the systolicand diastolic intervals for bruit candidates.

FIG. 61 is a flow chart depicting the noise cancellation process.

FIG. 62 is a flow chart depicting further details of the noisecancellation process.

FIG. 63 is a flow chart depicting further details of the noisecancellation process.

FIG. 64 shows the overlapping segments used in the spectralcalculations.

FIG. 65 shows a two-dimensional graphical representation of thelikelihood of bruits.

FIG. 66 is a portion of a bruit candidate table.

FIG. 67 shows the energy content of two different signals.

FIG. 68 shows a graph of the probability of a bruit as a function of thespectral signal-to-noise ratio.

FIG. 69 shows a plot of the values of the individual probabilityindicators for several entries in the bruit candidate table.

FIG. 70 is a flow chart depicting the processing of the identified bruitcandidates.

FIG. 71 is a flow chart depicting the generation of an individualprobability indicator for each bruit candidate.

FIG. 72 is a flow chart depicting further detail on the actualcalculation of an individual probability value for each bruit candidate.

FIG. 73 is a flow chart depicting the expansion of a single bruitprobability indicator into a 2-dimensional probability indicator infrequency and time.

FIG. 74 is a flow chart depicting the consolidation of all probabilityindicators into a single overall probability indicator.

FIG. 75 depicts an inverse time domain Gaussian distribution array for afirst bruit.

FIG. 76 is a graph showing the probability of one bruit in the timedomain.

FIG. 77 depicts an inverse frequency domain Gaussian distribution arrayfor a first bruit.

FIG. 78 is a graph showing the probability of one bruit in the frequencydomain.

FIG. 79 is a blank two-dimensional Gaussian distribution table.

FIG. 80 is a two-dimensional Gaussian distribution table populated withsample values.

FIG. 81 is a three-dimensional representation of a probability indicatorfor a single bruit candidate.

FIG. 82 is a two-dimensional Gaussian distribution table populated withsample values for a second bruit candidate.

FIG. 83 is a two-dimensional running total Gaussian distribution tablepopulated with sample values.

FIG. 84 is a three-dimensional representation of a probability indicatorfor multiple bruit candidates.

FIG. 85 is a graphical representation of all bruit candidates for onefile of cardiovascular sound signals.

FIG. 86 is a two-dimensional probability graph of the probability ofrepetitive bruits, with a single probability of bruits value alsodisplayed.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

System Overview

By way of an overview, the embodiments of the invention described hereinconcern systems and methods for identifying cardiovascular sound signalsthat are indicative of one more bruits, i.e., bruit candidates, and forgenerating a likelihood of cardiovascular disease that emphasizes theoccurrence of multiple bruits in one or multiple heart cycles.

Occlusions and other anomalies in the cardiovascular system are oftenassociated with various types of cardiovascular disease, such ascoronary heart disease. The presence of occlusions and otherabnormalities in the cardiovascular system, such as in the heart andblood vessels, is believed to be the source of abnormal sounds, referredto herein as “bruits,” that are associated with many different varietiesof cardiovascular disease. As used herein, “cardiovascular disease”refers to any of the abnormal conditions associated with thecardiovascular system, especially the heart and blood vessels. Set forthbelow are some examples of cardiovascular diseases that are known togenerate various types of bruits: acute alcoholic hepatitis; acuterheumatic fever (Carey Coombs murmur); anemia; aortic insufficiency(Austin Flint); arteriovenous fistula (systemic or pulmonic); atrialmyxoma; atrial septal aneurysm; atrial septal defect; atrioventricularjunctional rhythm; bacterial endocarditis; branch pulmonary stenosis;carotid occlusion; celiac mesenteric occlusion; chronic cor pulmonale;coarctation of aorta; complete heart block; congenital heart disease;high-to-low pressure shunts; rapid blood flow; secondary to localizedarterial obstruction; cor triatriatum; coronary artery disease; coronaryheart disease; coronary occlusion; diffuse endomyocardial disease;Ebstein's malformation; femoral occlusion; heart trauma, direct orindirect; hemiangioma; hpyerthyroidism; hyperemia of neoplasm (hepatomarenal cell carcinoma, Paget's disease); hypertensive heart disease;hyperthyroidism; hypertrophic cardiomyopathy; hypertrophic subaorticstenosis; intercostal muscle contractions; intraventricular tumors orother masses; left atrial tumor; left-to-right atrial shunting(Lutembacher's syndrome, mitral atresia plus atrial septal defect);mammary soufflé; marfan syndrome; mediastinal emphysema; membraneousventricular septal aneurysm; mitral commisurotomy; mitral insufficiency;mitral stenosis; mitral valve prolapse; myocarditis nylon chordae;papillary muscle dysfunction; pericardial effusion; pericardial heartdisease; pleural or pericardial adhesions; pneumoperitoneum;pneumothorax; polyarteritis nodosa; pulmonary septal defect (patentductus arteriosus); renal occlusion; spontaneous closure of ventricularseptal defects; systemic artery to pulmonary artery (patent ductusarterious, aortopulmonary window; truncus arteriosus, pulmonary atresia,anomalous left coronary, bronchiectasis, sequestration of the lung);systemic artery to right heart (ruptured sinus of Valsalva, coronaryartery fistula); systemic lupus erythematosus; torn porcine valve cusps;tricuspid valve prolapse; venous hum; venovenous shunts (anomalouspulmonary veins, portosystemic shunts); and ventricular septal defect.

There are many types of bruits that are associated with different formsof cardiovascular disease and that can be analyzed in accordance withembodiments of the invention. For example, a bruit may result from oneor more of the following types of murmurs: aneurismal murmurs; aorticmurmurs; apex murmurs; apical diastolic murmurs; arterial murmurs;attrition murmurs; Austin Flint murmurs; basal diastolic murmurs; CareyCoombs murmurs; continuous cardiac murmurs; cooing murmurs; crescendomurmurs; Cruveilheir-Baumgarten murmurs, diastolic murmurs; Duroziez'searly diastolic murmurs; early systolic murmurs; ejection murmurs;extracardiac murmurs; friction murmurs; Gibson murmurs; Graham Steell'smurmurs; Hamman's murmurs; hourglass murmurs; humming top murmurs; latesystolic murmurs; mid-diastolic murmurs; midsystolic murmurs; mitralmurmurs; organic murmurs; pansystolic murmurs; pericardial murmurs;pleuropericardial murmurs; prediastolic murmurs; presystolic murmurs;pulmonic murmurs; regurgitant murmurs; Roger's murmurs; seagull murmurs;stenosal murmurs; Still's murmurs; subclavicular murmurs; systolicmurmurs; tricuspid murmurs; vascular murmurs; venous murmurs; and otherknown and yet to be known murmurs. Categories of some bruits associatedwith cardiovascular disease include: bruits d'airain; aneurysmal bruits;bruits de bois; bruits de canon; bruits de clapotement; bruits declaquement; bruits de craquement; bruits de cuir neuf; bruits de diable;bruits de drapeau; false bruits; bruits de froissement; bruits defrolement; bruits de frottement; bruits de gallop; bruits de grelot;bruits de lime; bruits de Moulin; bruits de parchemin; bruits depiaulement; bruits placentaire; bruits de pot fêlé; bruits de rape;bruits de rappel; bruits de Roger; bruits de scie; bruits skodique;bruits de soufflet; systolic bruits; bruits de tabourka; bruits detambour; and Verstraeten's bruits.

For purposes of illustration, the following description concerns bruitsassociated with occlusions in the cardiovascular system of humans another mammals, which typically have frequency components that range from200-2000 Hz, often between 300-1800 Hz, more often between 400-1500 Hz,and most often between 400-1200 Hz. As will be appreciated, alternativeembodiments of the invention can be directed to bruits falling below 200Hz and above 2000 Hz. Also, while some bruits are observed in systole,for purposes of illustration, the following description focuses onbruits occurring in diastole. As will be apparent, the invention is alsoapplicable to bruits occurring in systole.

FIG. 1 illustrates a system 100 for acquiring and analyzingcardiovascular sounds in accordance with one embodiment of theinvention. The system 100 includes a sensor 110, which is a devicecapable of acquiring (i.e., sensing, detecting, or gathering)cardiovascular sound signals from a patient when placed on or near thepatient. Examples of sensors 110 that are suitable for the system 100include those described in U.S. Pat. No. 6,053,872, the entiredisclosure of which is hereby incorporated by reference.

Cardiovascular sound signals acquired by the sensor 10 may include thosesound signals emanating from the heart, blood vessels (i.e., arteries,veins, capillaries, etc.) and/or other portions of the cardiovascularsystem of mammals. For purposes of illustration, the followingdescription concerns an embodiment of the invention in which the sensor10 is placed on a patient's precordium to acquire cardiovascular soundsignals that include heart sound signals. However, the sensor 10 may beplaced at other locations. For example, in accordance with oneembodiment of the invention, the sensor 110 is placed on a patient'sback to acquire cardiovascular sound signals. In a further embodiment,the sensor 10 is placed on the neck or leg of a patient to acquirecardiovascular sound signals.

In the illustrated embodiment of the invention, the sensor 10 is asingle sensor that is placed at different locations on the patient forsequentially acquiring cardiovascular sound signals from the patient fora specified period of time. In this manner, the cardiovascular soundsignals are said to be gathered in series from different locations. Asis illustrated in FIG. 2, the cardiovascular sound signals acquired fromone location on the patient's percordium include a plurality (at leasttwo) heart cycle signals 92 to define one heart waveform signal 94.Similar waveforms of other cardiovascular sound signals may be acquiredfrom other areas of the body. In FIG. 2, the vertical axis isrepresentative of the amplitude of the acquired cardiovascular soundsignals and the horizontal axis is representative of time. In accordancewith the illustrated embodiment, the sensor 10 is placed at ninedifferent locations on a patient's precordium to acquire a heartwaveform 94 from each location for a total of nine acquired waveforms.More particularly, and as is illustrated in FIG. 3, the sensor 10 isplaced at nine locations R1, R2, R3, S1, S2, S3, L1, L2, and L3 on thepatient's precordium that form a 3×3 grid roughly over the patient'sheart. Hence, the sensor 10 will acquire cardiovascular sound signalshaving nine different heart waveform signals 94, where each heartwaveform signal has a plurality of heart cycles 92. In the preferredembodiment, the sensor 110 is located at each location R1, R2, R3, S1,S2, S3, L1, L2, and L3 for approximately one minute to acquire thedifferent heart waveform signals in series. In subsequent processing,the serially gathered physiological signals are processednon-coherently. In another embodiment of the invention, two or moresensors 110 are used to acquire cardiovascular sound signals inparallel. In subsequent processing, the parallel-acquired cardiovascularsound signals are processed coherently.

The cardiovascular sound signals acquired by the sensor 110 include atleast those frequencies where bruits are found. However, otherfrequencies may also be of interest or use. Hence, in the illustratedembodiment of the system 100, cardiovascular sound signals are acquiredin frequencies between dc and 2000 Hz so as to also encompass audible orpossibly inaudible acoustic signals emanating from the cardiovascularsystem, such as normal sounds of the heart and/or its adjacent veins andarteries. As will be appreciated, because the heart is not isolated fromthe body, the acquired cardiovascular sound signals will typicallyinclude other sounds as well, such as the sounds of air moving throughthe lungs. In an alternative embodiment of the invention, the acquiredcardiovascular sound signals only include frequencies in a limitedfrequency band, e.g., a 200-2000 Hz, 300-1800 Hz, 400-1500 Hz, or400-1200 Hz band. This may be accomplished with filters as is apparent.To provide ample frequency resolution for the identification of bruitcandidates in the acquired cardiovascular sound signals, in theillustrated embodiment of the system 100, the cardiovascular soundsignals are acquired in frequencies between dc and 2000 Hz at a samplingrate of greater than 4000 Hz, preferably at 8000 Hz. However, thecardiovascular sound signals can be sampled at a lower or greater ratethan 8000 Hz. For example, in an alternative embodiment, thecardiovascular sound signals are sampled at 2000 Hz or at 6000 Hz.

As is also illustrated in FIG. 1, the system 100 also includes abackground sensor 120 that acquires background (noise) sound signals.The background sensor 120 is a device capable of measuring, detecting,or gathering background sound signals from the patient and/or thepatient's surroundings. In the illustrated embodiment, the backgroundsensor 120 is an omni-directional microphone. The background soundsignals acquired by the background sensor 120 typically include variousacoustic vibrations, electrical interference, etc., that are generatedby or within proximity to the patient and that are generally considered“noise” or interference to the cardiovascular sound signals describedabove. These acquired background sounds signals are used to reduceand/or eliminate their effects on the acquired cardiovascular soundsignals as will become apparent. In the illustrated embodiment, thebackground sensor is located on a stable surface or table near thepatient to acquire any background sound signals while the cardiovascularsound signals are acquired via the sensor 110. FIG. 2 also illustratesan example of a noise waveform 96 acquired by the background sensor 120in parallel with the heart waveform signal 94 acquired by the sensor110, where the vertical axis is represents amplitude and the horizontalaxis represents time.

As is illustrated in FIG. 1, the cardiovascular sound signals that havebeen acquired by the sensor 110 and the noise signals that have beenacquired by the background sensor 120 are forwarded, either sequentiallyor in parallel, to a signal conditioning module 130 for conversion intodigital signals. The signal conditioning module 130 includes one or moreelectronic circuits that convert the analog sound signals from thesensor 110 into digital signals. In one embodiment of the invention, thesignal conditioning module 130 is an off-the-shelf module such as acommercial multi-channel 16-bit or greater analog to digital converter.In a further embodiment, the signal conditioning is performed by thesensor 110, the sensor 120, and/or the processor 150.

In the illustrated embodiment, the signal conditioning module 130 alsoreceives an electrocardiograph signal (“ECG signal”) from an ECGinstrument 140 that generates a record of the electrical currentsassociated with the patient's heart muscle activity. As is describedbelow in further detail, the ECG signal is used to detect various phasesof each heart beat cycle. Unfortunately, in some environments, an ECGsignal is not available or produces an unreliable signal. In accordancewith one embodiment of the system 100, the phases of each heart cycle ofa given heart waveform signal are determined without the reference ECGsignal.

The digital cardiovascular sound signals converted by the signalconditioning module 130 are forwarded to a processor 150, which is oneor more devices that that processes the digital cardiovascular soundsignals in accordance with programmed instructions, as set forth belowin greater detail. The processor 150 is configured to generate aprobability indicator indicative of the likelihood that a patient hascardiovascular disease in accordance with the previously programmedinstructions. The processor 150 may be a computer, a separate digitalsignal processor, or other processing device as would be apparent. Inthe illustrated embodiment, the processor 150 includes a memory orrecordable media that stores the acquired cardiovascular signals,intermediate results of processing, and the final output of theprocessor. The processor 150 may also include a preamplifier circuit,gain control circuits, filters, and sampling circuits. For example, inone embodiment, the processor 150 includes a signal analysis module, adigital signal processing module, and a commercially available personalcomputer. Various features of the processor 150 may be manually adjusted(e.g., gain control adjusted by the user) or automatically adjusted(e.g., automatic gain control) as would also be apparent. In a furtherembodiment, the previously described signal conditioning is alsoperformed by the processor 150. The processor 150 immediately processesthe cardiovascular sound signals and/or stores the cardiovascular soundsignals for processing at a later time. For example, in one embodimentof the invention, the processor 150 is located at the point-of-care ofthe patient and immediately processes the cardiovascular sound signalsat the point-of-care to generate the probability indicator indicative ofthe likelihood that the patient has cardiovascular disease. In anotherembodiment of the invention, the processor 150 is located at thepoint-of-care of the patient, stores the cardiovascular sound signals ina memory or computer storage media, and later processes thecardiovascular sound signals at the point-of-care to generate theprobability indicator indicative of the likelihood that the patient hascardiovascular disease. In a further embodiment of the invention, theprocessor 150 is located at a location remote from the point-of-care ofthe patient. In this embodiment, the cardiovascular sound signals areforwarded from the point-of-care to the processor 150 at the remotelocation, where the processor processes the cardiovascular sound signalsto generate the probability indicator indicative of the likelihood thatthe patient has cardiovascular disease. In a variation of thisembodiment, the cardiovascular sound signals are stored and transmittedto the processor 150 at the remote location from an intermediatecomputer located at the patient's point-of-care (not otherwiseillustrated). As will be appreciated, in this embodiment theintermediate computer could include the signal conditioning module 130.Additionally, the cardiovascular sound signals could be forwarded to theprocessor 150 in analog form, where the processor 150 defines the signalconditioning module 130 and performs the functions thereof. In variousof these embodiments of the invention, the cardiovascular sound signalsmay additionally be stored for purposes of building a knowledge baseover time for increasing the accuracy of generating the probabilityindicator indicative of the likelihood that the patient hascardiovascular disease.

In above-described embodiments of the invention where the cardiovascularsound and other signals are gathered or captured at the patient'spoint-of-care and transmitted to the processor 150 located elsewhere,the processor 150, subsequent to receiving the signals, generates aprobability indicator indicative of the likelihood that the patient hascardiovascular disease, such as heart disease, and forwards thegenerated probability indicator to the patient and/or the patient'shealth care provider. These embodiments of the invention are akin toforwarding blood samples drawn at the patient's point of care to alaboratory where the blood samples are analyzed and the results areforwarded to the patient and/or the patient's health care provider. Aswould be apparent, the “laboratory” for determining the probabilityindicator indicative of the likelihood that the patient hascardiovascular disease (i.e., the processor 150) may be co-located withthe point of care facility (i.e., within the doctor's office, thehospital, the hospital complex, etc.); may be associated or affiliatedwith the point of care facility (i.e., as with a managed healthcareprovider); or may be a laboratory independent of the point of carefacility (i.e., a local, regional, national, or international laboratorythat processes the cardiovascular sound signals from various, different,point-of care facilities).

Various mechanisms exist for forwarding the captured cardiovascularsound signals from the point-of-care to the processor 150 and forforwarding the generated probability indicator from the processor orother device to the patient, the point-of-care, and/or the patient'shealth care provider. For example, in one embodiment of the invention,the cardiovascular sound signals are transmitted to the processor 150over a network, such as the internet, a local area network, a wide areanetwork, a dedicated network, etc., using various well knowntransmission protocols. These networks may include one or more wired orwireless connections such as, for example, between the intermediatecomputer processor and the processor 150, as would be apparent. In oneembodiment, the cardiovascular sound signals are transmitted to theprocessor 150 via telephone lines. Likewise, in accordance with theseembodiments, the generated probability indicator is transmitted to thepatient, the point-of-care, and/or the patient's health care providerover a network, such as to the intermediate computer at thepoint-of-care. In a further embodiment, the cardiovascular sound andother signals are stored on a computer readable/writable medium, such asa magnetic disk, an optical disk, or portable RAM or ROM, which mediumis then forwarded to the laboratory, via mail, courier, or otherwise,where the processor 150 is located. The processor 150 retrieves theheart sound and other signals from the portable memory and thengenerates the probability indicator. The generated probability indicatoris then recorded on a paper or another portable memory and forwarded tothe patient, the point-of-care, and/or the patient's health careprovider for analysis and consideration as would be apparent.

In one embodiment of the invention, the cardiovascular sound signals areencrypted or secured in some fashion to address privacy concernsassociated with the patient as well as to address authentication,authorization, and integrity matters associated with the signals. Dataencryption and/or data security are generally well known. In theseembodiments, an identifier of the patient known to the patent and/orpatient's health care provider may be transmitted and/or stored with thesignals as would be apparent.

As is also illustrated in FIG. 1, the system 100 also include a displaydevice 195 that generates a graphical user interface for viewing andinterpreting intermediate and/or final results of the processingperformed by the processor 150. As will be appreciated, the signalconditioning module 130, the processor 150, the display 195, and theirassociated components may be part of a computer, workstation, or othercomputing device.

Signal Processing Overview

The flowchart in FIG. 4 depicts an overview of the process by which thesystem 100, and more particularly the processor 150, processes thereceived cardiovascular signals to eventually generate at a step 5000the probability indicator indicative of the likelihood that the patienthas cardiovascular disease (also referred to herein as the Flow MurmurScore). In a step 1000, the cardiovascular sound signals of the patientare acquired as set forth above. In the illustrated embodiment, thecardiovascular sound signals include nine heart waveform signals eachcorresponding to a different location where the cardiovascular soundsignals were acquired and each including a number of heart cyclesignals. Once the cardiovascular sound signals have been acquired instep 1000, parameters for subsequent processing are initialized, such asfilter parameters and sample rates associated with the audio data. Theseparameters are based on constraints associated with signal sources,measurement objectives, and experimentation. Examples of such parametersare listed below in Table 1. TABLE 1 Parameters for the calculation ofLikelihood of Cardiovascular Disease Parameter Description Value RangeDesired Wide Band Effective rate for decimated Wide 4.4 KHz 4 to 8 KHzSample Rate Band Time Data Desired Narrowband Band Effective rate fordecimated 440 Hz 300 to 1 Sample Rate Narrowband Band Time Data KHz HighBeat per Second Defines Maximum Heart Rate 2.5 2. to 4. Limit searchlimit Low Beat per Second Defines Minimum Heart Rate 0.6 0.3 to 1. Limitsearch limit Heartbeat Duration Count Defines Next Heartbeat Duration0.8 0.5 to 1.5 Tolerance Tolerance Window Minimum Beat Factor DefaultMinimum Heartbeat 0.65 0.5 to 1.5 Default Duration as fraction of meanHeartbeat Duration Minimum Beat Seconds Absolute Minimum Time in 0.360.1 to 1 Seconds to Next Heartbeat Minimum Beat Factor Low MinimumHeartBeat Duration as 0.51 0.2 to 1.0 Fraction of Mean HeartbeatDuration After Adjustment for S1- S2 Spacing Correlation Window S1-S2Interval Windowed for 0.65 0.5 to 1.0 Fraction Matching Match FilterEnvelope Fraction of Heart Beat Duration 0.125 0.05 to 0.2 Width CountTo Use As Width of Cosine Envelope in Building the Match Filter Gap RunThreshold Minimum gap in Seconds to hold a 0.055 0.01 to 0.2 PulseActive Pulse Length Threshold Minimum Pulse Length Threshold 0.035 0.01to 0.2 in Seconds Signal Fraction Threshold Minimum Fraction Thresholdof 0.2 0.01 to 0.5 Pulse Signal Max to Determine End of Pulse ComponentVernier Synch Shift Limit Max Shift Permitted in Vernier 0.03 0.01 to0.1 Synch Function expressed as a Fraction of the Heartbeat DurationFFTSize FFT Size for Bruit Spectral 128 64 to 256 Processing FFT OverlapRatio Overlap Ratio for FFT Segments 0.50 0.1 to 1.0 for Bruit SpectralProcessing Bruit Low Frequency Limit Low Frequency Bruit Detection 300200 to 500 Limit Bruit High Frequency High Frequency Bruit Detection1800 500 to 2000 Limit Limit Averaging Window Factor Width of SpectralAveraging 1.0 0.25 to 2 in Heartbeats Window as Fraction of MeanHeartbeat Duration For Bruit Processing Noise Cancel Frequency FrequencySeparation Limit for 1200 0 to 2000 Separation Cancellation Noise CancelTime Time Separation Limit in seconds 0.02 0 to 0.1 Separation forCancellation Noise Cancel Level Skew Level Applied to Suppress 0.99 0.0to 1.0 Noise Bruit 2nd Pass Noise Cancel Frequency Separation Limit for780 0 to 2000 Frequency Separation 2nd Pass Noise Cancellation BruitPower Detect Cutoff Lowest Bruit Spectral Power 14.0 dB 10 to 30 dBConsidered Bruit Power Detect 50 Percent Bruit Spectral Power 18.5 dB 10to 30 dB Midrange Probability Level Bruit Power Detect 90 90 PercentBruit Spectral Power 24.0 dB 10 to 30 dB percent confidence ProbabilityLevel Skew Cutoff Highest Skew Ratio Level 0.75 0. to 1. Considered SkewMidrange Value 50 Percent Skew Ratio Probability 0.56 0. to 1. LevelSkew 90 percent 90 Percent Skew Ratio Probability 0.38 0. to 1.confidence Level Prob(Bruit) rejection cutoff Lowest Bruit Probability0.09 0. to 0.9 Considered Bruits per Respiration Expected Number Bruitsper 2.0 0.1 to 5 Cycle Respiration Variance in Bruit Uncertainty ofBruit Frequency 75 Hz 0 to 500 Hz Frequency Measurement Variance inBruit Time Uncertainty of Bruit Time 20 ms 0 to 100 ms MeasurementProbability Site Covariance Probability Processing Covariance 0.5 0 to 1factor Probability Time Diastolic Probability Processing Diastolic 0.6secs 0 to 3.0 Window Time Window Cutoff in Seconds After S2

In summary, after the above parameters have been initialized, thecardiovascular sound signals are processed to identify common referencesin a step 2000. Thereafter, bruit candidates are identified in a step3000, which are then processed in a step 4000. As a result of theprocessing of the bruit candidates, a probability indicator is generatedin a step 5000 that indicates the likelihood that a patient hascardiovascular disease based, among other things, on the recurringnature of identified bruit candidates. In the embodiment set forthbelow, the above noted parameters are set for the detection of bruitcandidates indicative of coronary heart disease. As will be appreciatedthe parameters can be set such that the system 100 identifies otherbruits that are indicative of other cardiovascular diseases andgenerates one or more probability indicators indicative of such othercardiovascular diseases.

Identifying Common References in the Acquired Cardiovascular SoundSignals

The applicants have realized that the occurrence of bruit candidates atnearly the same time in different heart cycles can be, among otherthings, a strong indication of cardiovascular disease, especiallycoronary heart disease. Hence, as set forth above, one embodiment of theinvention concerns emphasizing the repetitive nature of bruit candidatesthat occur in multiple heart cycle signals. To identify when bruitcandidates occur at nearly the same time in different heart cycles, itis preferable to identify a common reference in each heart waveform,preferably in each heart cycle, from which the time location of thebruit candidates can be measured. Without such a common reference, it isdifficult to determine when bruit candidates occur at roughly the sametime in different heart cycles.

As is known, a heart cycle typically has two main components, termed“S1” and “S2.” S1 is the heart sound occurring during closure of themitral and tricuspid valves, often heard as a “lubb” sound. S1 beginswith an inaudible, low-frequency vibration occurring at the onset ofventricular systole, followed by two intense higher frequency vibratingbursts associated with mitral and tricuspid valve closure, and endingwith several variable low-intensity vibrations. S2 is the heart soundoccurring during closure of the two semilunar valves at the beginning ofdiastole, often heard as a “dupp” sound. S2 typically includes two sharphigher frequency vibrations representing closure of the aortic thenpulmonary valves. Some heart cycles also include components termed “S3”and “S4.” S3 is the heart sound associated with lower frequencyvibration of the ventricular walls during rapid ventricular filling inearly diastole. S3 is often termed “S3 gallop rhythm.” S4 is the heartsound associated with atrial contraction, occurring during thepresystolic phase of diastole. S4 is often termed “S4 gallop rhythm.”“Diastole” is the period of dilatation of the heart, especially of theventricles; it coincides with the interval between S2 and the next S1.“Systole” is defined as the contraction, or period of contraction, ofthe heart, especially that of the ventricles, sometimes divided intocomponents, as pre-ejection and ejection periods, or isovolumic andejection. A typical waveform of a heart cycle will consist of an initialburst of energy (S1) lasting on the order of 150 milliseconds, a quietperiod (systole) lasting about 200 milliseconds followed by a secondburst of energy (S2) lasting about 100 milliseconds. The period from theend of S2 to the start of the next heartbeat (diastole) is usually quietbut may exhibit S3 and S4 under certain conditions. Cardiovasculardiseases, such as arrhythmia or valve disease, may distort the S1through S4 pulses. The energy of the S1 through S4 pulses is usuallyconfined to a frequency band between zero and 150 Hz, where the peakfrequency is usually on the order of 30 Hz.

As is known, a signal derived from electrical potential heart signals,such as a healthy ECG signal, typically includes one strong, narrow,bi-polar pulse occurring just prior to the onset of the S1 pulse. Theother components of a typical ECG waveform are relatively weak. If welldefined, the ECG signal provides an excellent medium in which to locatethe start of each individual heart cycle, which can also serve as thecommon reference for each heart cycle. Alternative signals that may beused to locate the start of each heartbeat cycle include blood pressureor blood flow sensors, such as optical sensors. If an ECG or similarsignal is available, then it is used at step 2000 to identify a commonreference for each heart cycle. In many instances, however, an ECG orsimilar signal is not available, or, even if available, is not clearenough to provide a reliable indication of the start point of the heartcycle. Hence, in accordance with the illustrated embodiment of theinvention, at step 2000 the system 100 processes the acquiredcardiovascular sound signals to determine the common reference of eachheart cycle without the assistance of a signal derived from electricalpotential heart signals, such as an ECG or a similar signal. FIG. 5illustrates one embodiment of processing the acquired cardiovascularsounds of a patient to determine a start point or an end point of one ormore phases of each heart cycle signal, i.e., a common reference.

To determine the start point of each heart cycle without the assistanceof an ECG, an estimate is made of where S1 and S2 generally fall withineach heart cycle. The presence of both the S1 and S2 pulses in theheartbeat audio, coupled with the wide variations that can be presentamong individuals, makes it difficult to isolate S1 and S2 without anECG signal. In a normal resting heartbeat, the recorded heart cyclesignals for each heartbeat are essentially identical and occurrepetitively at a nearly fixed rate. When these conditions are present,the determination of the periodicity of the heart rate isstraightforward. In practice, however, many factors, such as arrhythmia,contribute to degrade the quality of each heart beat such that they arenot identical and do not occur at a fixed rate. The processing of thecardiovascular sound signals at step 2000 is focused on the twoprincipal pulses within each heartbeat (S1 and S2); the audiofrequencies inherent to these pulses are typically below 100 Hz. As setforth above, the cardiovascular sound signals are acquired infrequencies between dc and 2 kHz at a sampling rate of greater than 4kHz. To minimize the computing time for processing the cardiovascularsound signals, a narrow band version of the cardiovascular sound signalsis produced by further re-sampling of the acquired cardiovascular soundsignals at step 2100 to produce a reduced bandwidth wide band for eachheart waveform. In sum, the acquired cardiovascular sound signals arefiltered and decimated to a sample frequency upper limit of 4 kHz. Thistransformation to a lower sampling rate speeds up subsequent processingand reduces memory space requirements while maintaining a frequencyresolution in excess of 2 kHz. FIG. 6 illustrates one preferred methodof preparing the cardiovascular sound signals at step 2100 in greaterdetail.

In a step 2102, a wideband decimation factor is computed based on whatis needed to reduce the input bandwidth to a nominal 2000 Hz bandwidth.This factor allows the acquired cardiovascular sound signals to bedecimated by a particular factor to, among other things, reduce storageand computing requirements while not sacrificing audio quality.Similarly, in a step 2103, a narrowband decimation factor is computedbased on what is needed to reduce the input bandwidth to a nominal 200Hz bandwidth. In one embodiment, both the wideband and narrowbanddecimation factors are set equal to 10.

In a step 2104, the acquired cardiovascular sound signals are low passfiltered and decimated using the wideband decimation factor. In oneembodiment, a rapid implementation of a low pass filter is a successivesumming of heart waveforms displaced by sample counts according to theFibonacci sequence, producing a wideband cardiovascular dataset (orwideband heart audio signal). Other similar low pass filter functions,such as a Bessel or Finite Impulse Response (FIR) filter, could also beused. In a step 2105, the wideband cardiovascular dataset is normalized,and in step 2106, correction for clipping (if it has occurred) takesplace by replacing any clipped peaks with interpolated cosinetransforms.

In a step 2107, the wideband cardiovascular dataset is further processedby performing a zero mean function on it. The zero mean functionnormalizes any A/D bias offset by subtracting the mean value of thewideband cardiovascular dataset from all sample points. In a step 2108,the normalized wideband cardiovascular dataset is then peak scaled to avalue of one.

In a step 2109, the wideband cardiovascular dataset is low pass filteredusing a Fibonacci sequence and decimated using the narrowband decimationfactor. The filtering is a successive summing of waveform samples spacedaccording to the Fibonacci sequence, producing a narrowbandcardiovascular dataset, which is stored in a memory for later use.

As is apparent, other sampling rates and frequency resolutions willsuffice, so long as the Nyquist criteria are satisfied for thefrequencies of interest. Hence, in accordance with another embodiment ofthe invention, step 2100 includes data sampled at 44 kHz and decimatedto a bandwidth of 2200 Hz.

In one embodiment, a similar decimation process is carried out on thebackground noise to decimate and filter to a wideband sample rate forpurposes of canceling anomalies induced by the noise. Once thecardiovascular sound signals have been prepared in step 2100 of FIG. 5,at a step 2200, the start point of each heart cycle signal (i.e., eachheart beat) within the acquired cardiovascular sound signals isdetermined, as described in further detail below.

Determining a Start of Each Heart Cycle

As is illustrated in FIG. 5, after the cardiovascular signals have beenprepared, at a step 2200, the start points of the heart cycles withineach heart waveform of the acquired cardiovascular sound signals arethen determined. To summarize this process, successive estimates of aheartbeat power envelope are used as a matching filter to locate heartbeats in the cardiovascular sound signals. Correlations are thenperformed to find matches between a peak detect envelope and thecardiovascular sound signals. The peak detect envelope is a time domainrepresentation of a signal that has peaks indicative of the estimatedpeaks in the heart waveform. An autocorrelation is performed todetermine an initial estimate of heart rate, and the narrowbandcardiovascular sound signals are then further processed to make aninitial estimate of S1 to S2 spacing. Once the correlations are carriedout, an analysis of the peaks is then conducted to isolate those peaksthat most likely belong to the heartbeat sequence. During this analysis,a parsing score is carried along with the peak analysis results toquantify the quality of the process of predicting the start points ofeach heart cycle. If the parsing score for the peak analysis processbased on the peak detect envelope reflects that detected peaks do notaccurately align with all of the actual cardiovascular sound signals,then additional processing is carried out. During this additionalprocessing, successive individual peak estimates from the peak detectenvelope are correlated against all of the cardiovascular sound signalsuntil a perfect match is found or until all of the successive heartcycle signal envelopes are processed. The peak analysis programprocesses each set of peak estimates and provides the parsing score forthe set. If a perfect parsing score is obtained from one of the peakestimates from the peak detect envelope, the results are acceptedwithout further processing. Step 2200 is now described in further detailbelow in reference to FIG. 7.

In a step 2205, smoothed cardiovascular sound signals are generated inorder to smooth the peaks in each heart cycle signal. In particular, asdetailed in FIG. 8, a time sample search range is computed in narrowbandtime sample points in a step 701 for the heart rate of thecardiovascular sound signals. In an embodiment, a nominal heart ratesearch range with limits of 0.6 Hz to 3.0 Hz are divided into the samplerate to define the search limits. Next, in a step 702, a band-passfilter or similar filtering is applied to the narrowband cardiovasculardataset to help isolate the principal components that make up the S1 andS2 pulses in the heartbeat. In one embodiment, the band pass filter iscentered at 40 Hz and has a 3 dB roll-off at +/−20 Hz away from center,although other filters could be used as would be apparent.

In a step 703, a 0.1 second time sample array of ones (i.e., a unityaveraging smoothing window) is defined for use in a low pass filterprocess. In other embodiments, a Blackman, Gaussian, or Kaiser-Besselwindow could be used. To avoid multiple peaks from high frequencycomponents of S1 and S2 pulses within one each heart cycle, the bandpassed narrowband cardiovascular dataset is converted by an absolutevalue function in a step 704 and then low-pass filtered in a step 705 byconvolving it against the unity averaging smoothing window. Thisconvolution smoothes the envelopes of the beat structure to produce thesmoothed cardiovascular sound signals. For example, FIG. 9 illustratesthirty seconds of one heart waveform 820 of the smoothed cardiovascularsound signals and FIG. 10 illustrates 2.5 seconds of smoothedcardiovascular sound signals.

Referring again to FIG. 7, the smoothed cardiovascular sound waveformgenerated in step 2205 is then convolved with itself in a step 2210 togenerate an autocorrelation that can be used as an initial estimate ofthe start point of each heart cycle signal within the acquiredcardiovascular sound signals. Each point in the generatedautocorrelation represents the sum of the products of the waveform withthe same waveform shifted by incremental amounts. As is illustrated inFIG. 1, a typical generated autocorrelation has a central or primarypeak 1010 where the waveform aligns with itself and a series ofsecondary peaks 1020, 1030 of reduced amplitude at spacingscorresponding to the alignment of similar waveforms. Thus, theautocorrelation of a repetitive time waveform consists of well-definedcentral and secondary peaks with nominally equal spacings that match theheartbeat period. The spacing between the primary peak 1010 and adjacentsecondary peaks 1020, 1030 is indicative of the nominal heart rate. Inthe example shown in FIG. 11, the primary to secondary peak separationis approximately 0.8 seconds implying a heart rate of approximately 75beats per minute. This example also shows the presence of a pair ofsub-peaks 1040 situated between primary peak 1010 and secondary peak1030. Because of the similarity of the envelopes of the S1 and S2 soundpulses, the generated autocorrelation of the audio waveform willtypically have additional peaks (sub-peaks 1040 in FIG. 11) in betweenthe primary and secondary peaks. Heart cycle signals with a very weak S2pulse may not have sub-peaks. When S2 is centrally located in theheartbeat interval, only one centered sub-peak will typically bepresent. When S2 is spaced away from the center of the heartbeatinterval, two sub-peaks will typically be present, as shown in FIG. 11.

Referring again to FIG. 7, from the autocorrelation that was calculatedin step 2210, a beat duration estimate is generated in a step 2213 and amath model envelope is generated in a step 2215. The generation of thebeat duration estimate is illustrated in FIG. 12 and provides anestimated value for the duration of one heart cycle. To calculate thebeat duration estimate, the steps shown in FIG. 12 are carried out inaccordance with one embodiment of the invention.

As is illustrated in FIG. 12, in a step 1202 the principal (i.e.,largest) peak in the autocorrelation array of autocorrelation peaks fromthe complete heart audio recording is located. This is typically theprimary peak 1010 illustrated in FIG. 11. Next, in a step 1204 thesecondary (or second largest) peak in the array of autocorrelation peaksis located. This is typically one of the secondary peaks 1020, 1030illustrated in FIG. 11. Generally, the time between the principal peakand secondary peak will correspond to the period of the mean heart rate,so the separation of the principal peak and the secondary peak is storedas the heart rate. At a step 1206, the initial beat count (in samples)is stored as an initial beat duration estimate. The beat durationestimate represents the number of samples for one heart cycle signal. Ata step 1208, the details of which are illustrated in FIG. 13, any otherpossible secondary peaks in the autocorrelation peaks indicative of adifferent beat count or heart rate are processed. These peak candidatescould represent harmonics of the heartbeat or peaks that have beeninduced by arrhythmia. In particular, at a step 1302 of FIG. 13, adetermination is made of whether a third peak candidate is close to thesecondary peak. If so, tests are performed of whether this third peakshould be considered as a valid peak. In a step 1306, a test determineswhether the third peak is simply a harmonic of the heartbeat. If so, thethird peak is ignored. In a step 1308, a test determines whether thethird peak is actually part of the next heart cycle region and if so,the third peak is ignored. In a step 1310, a test determines if thewidths of the peaks have been increased by arrhythmia. If the peaks havebeen affected by arrhythmia, they will be smeared or spread out overtime. If the peaks are determined to be widened by arrhythmia, thesecondary peak and the third peak are both determined to be secondaryvalid peaks. Accordingly, in a step 1312, the sample positions of thepeaks are averaged. The heart rate estimate is based on the number oftime samples between the primary and the secondary peak positions. Afterthe beat duration estimate is generated, the math model envelope isgenerated.

Referring back to step 2215, using the number, location and amplitude ofsub-peaks 1040, the math model envelope is generated, which is anestimate of the heartbeat power. The math model envelope approximatesthe positions of S1 and S2 in the heartbeat cycle, and the widths andrelative amplitudes of the S1 and S2 pulses. The relative amplitude ofS2 is estimated based on the amplitudes of sub-peaks 1040 relative tothe primary peak 1010, and the position of S2 is estimated based uponthe separation of the two sub-peaks 1040. The calculation of the mathmodel envelope, according to an embodiment of the invention, is shown inthe flow chart in FIG. 14. At a step 1402, the second derivative of thenarrowband cardiovascular data set between the time domain locations ofprincipal peak 1010 and secondary peak 1030 (i.e., one beat duration) iscalculated. The calculation of the second derivative identifies allpeaks and valleys in the narrowband cardiovascular sound signals. Theresults of the second derivative calculation are stored in a peak/valleyarray (“pkconv”) in one embodiment of the invention. Once thepeak/valley array is calculated and stored in step 1402, all peaks inthe array are located in a step 1404. The peak locations are stored in asecond array (“cpksix”) according to an embodiment of the invention. Apeak count is also stored, which is the number of peaks in thepeak/valley array.

If more than two peaks are located in the pkconv array by a test in astep 1406, a valley value index (i.e., trough value) is determined in astep 1408 using the second index of the first valley in the pkconvarray. A test is then performed at a step 1410 to determine if thepreviously calculated beat duration estimate covers two beats, since astrong second peak may actually be indicative of a true next beat. In anembodiment, the test is whether (1) the absolute value of two times themaximum peak location subtracted from the beat duration estimate is lessthan 2% of the beat duration estimate and (2) the amplitude of the peaklocation with the maximum value is greater than 85% of the second peak.If both conditions of step 1410 are true, the peak that meets thosetests is considered to be the secondary peak, and the peak indices areupdated in a step 1411. If there are not more than two peaks in thepeak/valley array, control passes from step 1406 to a step 1412, where avalley value index (i.e., trough value) is determined using the index ofthe first sub-peak.

In a step 1414, a determination is made of whether any third peaks wereidentified in step 1406 but no peaks in the range of the beat durationestimate. If so, the peak indices in the peak/valley array are shiftedin a step 1416 to account for the actual beat duration. At a step 1418,control passes to FIG. 15.

In a step 1502 in FIG. 15, the sample index of the 3 dB roll offlocation of principal peak 1010 is determined. This will be used todetermine an estimate of the proper width of the math model envelope. Inone embodiment, this determination is made between the zero index ofprincipal peak 1010 and 1/7 of the beat duration estimate. In a step1504, a half cosine envelope of a fraction of a beat is computed, whichwill serve as the basis for the eventual calculation of the math modelenvelope. This is expanded by the 0.1 second smoothing filter width innarrowband sample points. Once the half cosine envelope is calculated, adetermination is made in a step 1506 of the center index of a nominal S1peak location. In an embodiment, the nominal S1 peak location (“slpk”)is determined by rounding the product of the half cosine envelope widthand the value 1.5.

Once the nominal S1 peak location is determined, a set of tests are madeto determine a nominal S2 peak location. In a step 1508, the peak countdetermined in step 1404 is tested to determine if it is zero (i.e., nopeaks were identified). If so, a default location for the S2 peak isassigned in a step 1510, based on the nominal S1 peak location. In anembodiment, this default location for S2 is determined by rounding theproduct of the beat duration estimate and 0.35 and then adding theresult to the nominal S1 peak location. Then, in a step 1512, nominalamplitude values for both S1 and S2 are assigned. In accordance with oneembodiment, the nominal amplitude value for S1 is 1, and the nominalamplitude for S2 is less than 1 and greater than 0, such as 0.7 or 0.85.

If the check in step 1508 reveals that sub peaks were found in theautocorrelation, a check is then made in a step 1514 of whether just onesub peak was found or more than one sub peak was found. If only one subpeak was found, the index of the maximum value in the peak/valley arrayis determined in a step 1516. Once the index of the maximum value isdetermined, that index is checked against the index for the S1 peaklocation at a step 1518. If the values are the same, a nominal value forthe S2 offset is assigned in a step 1520. If the values are not thesame, an S2 offset is calculated in a step 1526, based upon theseparation of the principal peak 1010 and the S2 subpeak. Next, adetermination is made in a step 1528 of the actual S2 peak location.

If more than one sub peak was found in step 1514, the indices for thetwo maximum values are determined in a step 1522. In a step 1524, an S2offset is calculated based on the separation of the principal peak 1010and the later-occurring of the two peaks, followed by a determination ofthe actual S2 peak location in step 1528. If either one or more than onesub peak was found, the initial amplitudes for S1 and S2 are assigned ina step 1530. Control then passes to the flow chart shown in FIG. 16 at astep 1532.

In a step 1602, a measure is made of any arrhythmia in thecardiovascular sound signals by creating a histogram of single pulseintervals measured from S1 to S2 and S2 to S1. The location of the twomajor peaks in the histogram provides independent measures for thesystolic and diastolic pulse intervals. An arrhythmia factor iscalculated as the difference between the sum of these two average pulseintervals and the interval of the average heartbeat cycle. This measurewill be insignificantly small if heartbeat cycle intervals areconsistent. The difference will become large if significant arrhythmiaspreads the range of diastolic intervals. Step 1604 finds the averagepower in the systolic pulses accumulated near the histogram peak of S1pulses. Step 1606 finds the average power in the diastolic pulsesaccumulated near the histogram peak of S2 pulses. A power measurement isthe means of the sum of the squares of the amplitudes of the timesamples within the envelope under consideration (e.g., the S1 or S2envelope).

In a step 1608, a test is done to determine whether (a) there isinsignificant arrhythmia in the cardiovascular sound signals and (2) thespacing between the S1 and S2 peaks is normal. There is insignificantarrhythmia if the spacing between S1 and S2 is normal and does not varyby less than a threshold of 10 samples. If both conditions are true, atest is done then performed in a step 1610 of whether the systolic poweris greater than zero. Then a power ratio is calculated in a step 1612that is equal to the diastolic power divided by the systolic power,which will be used to determine the initial S1 and S2 amplitudes. If thesystolic power is not greater than zero, the ratio is set to theexisting S2 amplitude value. Next, in a step 1616, the ratio is testedto determine if the diastolic power is greater than the systolic power.If so, the S2 amplitude is normalized to a value of 1, and the S1amplitude is set to a value of 1/ratio. If the diastolic power is notgreater than the systolic power, the S2 amplitude is set in a step 1624to the value of the ratio. Once the S1 and S2 amplitudes have been set,any necessary clipping of the S1 or S2 amplitudes (to a maximum value ofone) is performed in a step 1622. Thereafter, the control then passes toFIG. 17 at a step 1626.

In a step 1702 shown in the flowchart in FIG. 17, the S1 component ofthe math model envelope is calculated by building a cosine envelopeusing the values determined for the S1 peak location and duration in theprevious steps. Likewise, in a step 1704, the S2 component of the mathmodel envelope is generated. In a step 1706, a zero mean calculation isperformed on the math model producing the final math model envelope ofstep 2215.

For the waveform shown in FIG. 10, the analysis of data from theautocorrelation results (including the two sub-peaks 1040) describedabove results in the mathematical model of the signal envelope (i.e.,math model envelope) shown in FIG. 18. As will be appreciated, othermath model envelops of S1 and S2 can be generated in other manners, suchas a time scaled representation of a typical heart waveform.

Referring back to FIG. 7, after the math model envelope and the beatduration have been estimated, at a step 2220, the start points of theheartbeats are determined and a bootstrap filter envelope is generated.The details of step 2220 are illustrated in FIG. 19. In reference toFIG. 19, a number of parameters are initialized in a step 1902 tocontrol the selection of the beat correlation peaks in a correlationtest. Table 2 sets forth a list of exemplary parameters that are basedon the known parameters of patient heartbeats, along with a briefdescription thereof: TABLE 2 Peak detection parameters Beat CountTolerance = 0.8 Fractional Heartbeat Tolerance Correlation Window Factor= 0.7 Fraction of Beat Count to Correlate Minimum Beat Factor Default =0.65 Default minimum heart beat duration ratio limit MinBeatFactLow =0.51 Minimum acceptable heart beat duration ratio cutoff MinBeatRatio =value <1.0 Minimum acceptable beat duration as a fraction of the nominalbeat count MinBeatSeconds = 0.36 Absolute minimum time in seconds tonext heart beat

Continuing in a step 1902, the minimum beat duration count to beacceptable for parsing is defined as the Minimum Beat Duration Ratio. Ifthe S2 offset from the previous processing (step 1520 or 1526) isgreater than zero, then a value is assigned to the Minimum Beat DurationRatio equal to the S2 offset plus a constant offset. If the Minimum BeatDuration Ratio is less than the MinBeatFactLow parameter, it is setequal to the MinBeatFactLow value.

In a step 1904, a Kaiser-Bessel weighting window is defined, which willbe used in an automatic gain control process to level out the amplitudesof the correlation pulses. To account for physiological variations inthe strength of heartbeats, a gain normalization function (GN) may beapplied, which will balance the level of energy in each heartbeatinterval. In one embodiment, the GN utilizes a Kaiser weighting windowor similar window with an extent equal to the average heartbeat, aswould be apparent. This defines the left and right skirt amplitude to be10 percent of the central maximum. In a step 1906, this window is thenconvolved with the low-pass filtered version of the smoothedcardiovascular sound signals in FIG. 9 to produce a GN value for everytime sample. The waveform is then divided by the GN values so that thesum of the amplitudes under any heartbeat window is the same value. Thisprocess helps to level the series of start point peaks that might befound in the auto-correlation function described below.

Next, in a step 1908, the math model envelope, such as that shown inFIG. 18, is correlated against the smoothed cardiovascular soundsignals, such as those shown in FIG. 9. The result of this correlationis then divided by the AGC values in a step 1910, which creates a signalconsisting of a set of leveled peaks, such as shown in FIG. 20, for usein determining the start points of the heart cycle signals.

The leveled peaks shown in FIG. 20 represent the time indices at whichthe math model envelope of FIG. 18 best matches the individual heartbeatwaveforms in FIG. 2. These time indices locate the onset of an S1 pulsethat is a suitable heartbeat start point indicator in lieu of an ECG. Inan alternate embodiment, an ECG can be used to provide these heartbeatstart point indicators.

In the heart audio waveform used in this example, the envelopes of theS1 and S2 pulses are very well defined, which permits the analysis ofthe convolution process to provide a relatively accurate estimate of theheartbeat envelope which in turn will produce well defined peaksrepresenting the start of each heartbeat. In one embodiment, step 2220ends here if a parsing score of 1.00 is achieved, indicating noanomalies in the peaks from the correlation function. In some cases,however, the peaks are not so clear, such as when the heartbeatwaveforms are distorted from various physical disorders of the heart.For this reason, additional steps are taken to provide a more accurateestimate of the heartbeat envelope.

The data corresponding to the waveform of FIG. 20 is next processed tolocate the peaks that occur at times best fitting the nominal heart rateestablished in the steps described above. The process of finding thelocation of individual heart cycle signals generally requires a suitableheartbeat envelope that will correlate highly with all beats in thecardiovascular sound signals. A further refined model of the heartbeatenvelope is derived from the parameters of the sub-peaks in thecross-correlation shown in FIG. 20. In general, a predetermined numberof the strongest correlation peaks is used to identify actual heartcycle signals. The heart cycles associated with these peaks are averagedto form a bootstrap filter, which is more characteristic of the heartcycle signals corresponding to the heart cycles in the sampled audio.

More specifically, a bootstrap filter is created to further improve thewaveform model and raise the parsing score. Using the predicted startpositions of heartbeats from the math model filter, a predeterminednumber of strongly correlated matches (as determined by their amplitude)are selected at a step 1912 and then used to develop a new averagewaveform with which to search for the starts of heartbeats. Thispredetermined number of single heart cycle signals, selected fromdifferent intervals in the sample, is then at a step 1914 averaged toform a new estimate of the heartbeat waveform. In one embodiment, thepredetermined number is five; in an alternative embodiment thepredetermined number is three.

Since the heartbeat spacings from a patient with severe arrhythmia candepart widely from the expected spacing, as a final step in theformation of the bootstrap filter in one embodiment, a Kaiser filter isused to suppress points beyond the S2 location. While the best-fitalgorithm seeks out the peaks that most likely represent the start ofthe heart beat cycle, the similarity of the S1 and S2 pulses within theheartbeat can often cause a subsequent S1 peak to affect the convolutionwaveform. Processing with the Kaiser window achieves the goal ofminimizing the effects of any S1 signals early in subsequent heartcycles that might have contributed to the region after S2 (e.g., due toarrhythmia), by using a weighting factor that eliminates any potentialcontributions that spurious S1 signals might have caused.

The resulting average envelope is the bootstrap filter of step 2220 thatbears a close resemblance to at least some of the heartbeats within thefile. FIG. 21 illustrates one example of a bootstrap filter produced bythe heartbeat averaging process in an embodiment using three beataveraging.

Referring back to FIG. 7, at a step 2225, the bootstrap filter shown inFIG. 21 is then convolved with the cardiovascular sound signals shown inFIG. 2 to produce a signal with peaks that more accurately represent thestart of the heartbeats. FIG. 22 illustrates an example of a series ofpeaks resulting from this convolution process. The series of peaks inthe start point detect signal are then parsed to determine if thebootstrap filter has accurately modeled the heart cycle signals.

In particular, at a step 2230 of FIG. 7, a current best parsing scorevalue and an index into the peak detect signal are initialized. In oneembodiment, these are initialized to zero. Next, the set of peaks fromthe current convolution process (which, for the initial pass, will bethe peak detect signal shown in FIG. 22) is parsed in a step 2235 toextract the apparent start point of each heartbeat interval.

The flow chart in FIG. 23 depicts the details of the start pointextraction process shown in step 2235 of FIG. 7. In a step 2302,parameters for the start point extraction process are initialized,including the beat duration estimate tolerance value, the minimum beatduration threshold, and the measured S1 peak to S2 peak offset.

In a step 2304, an array of peaks is generated from the correlation ofthe bootstrap waveform and the entire array of cardiovascular soundsignals. The peaks are determined by a process of taking the sign of thedifference of the sign of the difference between successive points inthe array of the correlation peaks shown in FIG. 20 or FIG. 22. Thisresults in an array with a value of −1 at the peak locations, +1 at thenegative peaks, and a value of 0 elsewhere. Once the array of ones andzeroes is determined, negative peaks are discarded and the −1's areinverted to +1s. The entire array is then multiplied by the originalsmoothed narrowband cardiovascular sound signals in a step 2306,producing an array that contains the amplitude of each peak at alocation corresponding to the heartbeat start time in the originalcardiovascular sound signals.

Once the array of peak values is determined, that array is used in astep 2308 to determine a table of start point values that is greaterthan a predefined threshold. FIG. 24 provides further details of thegeneration of the table of start point values. In particular, at a step2402 a set of parameters is initialized, including a counter of thenumber of candidate peaks, which, in one embodiment, is set to a valueof 0. At a step 2404, the maximum number of peaks in the array of peakvalues is determined, and at a step 2406, a starting point for thepredefined threshold is determined. In an embodiment of the invention,the starting point for that predefined threshold is a value 10% lessthan the maximum peak amplitude value in the array of peak values.

In a step 2408, a determination is made of whether the number of peakvalues above the predefined threshold in the array of peak values isless than the maximum number of beats expected in the cardiovascularsound signals. If so, it would mean that a start point value has not yetbeen determined for each heart cycle signal within the cardiovascularsound signals. Accordingly, in a step 2410, a test is first made ofwhether the current predefined threshold value is greater than theminimum threshold value. As long as the current predefined thresholdvalue is greater than the minimum threshold value, the start point tableis populated in a step 2412 with values greater than the predefinedthreshold and the predefined threshold is updated in a step 2414. Thisloop continues until either the number of peak values in the start pointtable is no longer less than the number of heart cycle signals in thecardiovascular sound signals, or the predefined threshold is no longergreater than the minimum threshold.

Referring again to FIG. 23, after determining the start point table instep 2308, the duration of each heart cycle signal is determined in astep 2310. These duration values are determined by calculating thenumber of sample points between each start point value in the startpoint table.

Referring to FIG. 7, at a step 2240, a parsing score is calculated basedon the expected start points in the start point table determined in step2308. FIG. 25 details step 2240. In particular, at a step 2502, eachpeak in the start point table is evaluated to determine if it is anactual start point.

FIG. 26 further details the process shown in step 2502 of evaluatingeach peak in the start point table. The evaluation of each peakgenerally falls into three categories. In the first category, as testedin a step 2604, the duration from the current peak to the next peak isless than the minimum beat duration. As detailed in subsequent flowcharts, the other two categories are when the duration from the currentpeak to the next peak is within the beat count tolerance, and when theduration from the current peak to the next peak exceeds the beat counttolerance.

If the duration from the current peak to the next peak is less than theminimum beat duration, a further check is made in a step 2606 of whetherthe current start point is the last start point in the start pointtable. If so, the current start point is deleted from the start pointtable in a step 2608 and the deleted start points counter is incrementedin a step 2610. If the current peak does not correspond to the laststart point in the start points table, a check is then made in a step2612 of whether the current start point is the first start point in thestart points table. If so, the current start point and any immediatelysubsequent start points with a duration less than the minimum beatduration are discarded in a step 2614.

If, in step 2612, a determination is made that the current start pointis not the first start point in the start points table, then the currentstart point is in the middle of the cardiovascular sound signals andmust be processed. Accordingly, in a step 2616, the duration from thecurrent peak to the next peak is added to the preceding duration and ina step 2618 the current peak is discarded as an invalid peak. Since thecurrent peak has been discarded, the remaining entries in the peak valuetable are adjusted in a step 2620. In an embodiment of the invention,this adjustment consists of moving the remaining entries in the startpoints table down by one entry and adjusting all appropriate pointersand counters.

Referring back to step 2604 shown in FIG. 26, if the duration from thecurrent peak to the next peak is not less than the minimum beatduration, control passes at a step 2622 to FIG. 27. In a step 2702 inthe flowchart of FIG. 27, a determination is made of whether theduration from the current peak to the next peak is within the beat counttolerance. If so, a test is then made at a step 2704 of whether theduration corresponding to the current peak combined with the durationfor the next peak is less than the beat count tolerance. If so, and theduration for the next peak, as tested in a step 2706, does not fall intothe S1 to S2 peak gap, then the duration corresponding to the currentpeak is added to the duration corresponding to the next peak, and thetotal is stored as the current peak interval in a step 2708. Then, in astep 2710, the next point is discarded as an invalid start point and theremaining entries in the start point table are adjusted in a step 2712.In an embodiment of the invention, this adjustment consists of movingthe remaining entries in the start points table down by one entry, andadjusting all appropriate pointers and counters (including incrementinga deleted peaks counter).

If the heart beat cycle duration corresponding to the current peak, whenadded to the duration corresponding to the next peak, is not less thanthe beat count tolerance (as tested in step 2704), or if the durationcorresponding to the next peak does fall into the S1 to S2 peak gap (astested in step 2706), control passes to a step 2714. In step 2714, adetermination is made of whether there are unlisted peaks to process. Ifso, any unlisted peaks that were not entered into the start points tablebecause they were below the threshold are tested in a step 2716. Thistest will determine whether any of those unlisted peaks actually providea better fit when compared against the beat duration estimate. If nomore peaks are left to process, as tested in step 2714, the next peakvalue is accepted as a valid peak by incrementing the valid peakcounter. Referring back to step 2702, if the duration from the currentpeak to the next peak is not within the beat count tolerance, controlpasses at a step 2120 to FIG. 30.

FIG. 28 provides additional detail of the search process for unlistedpeaks shown in step 2716 in FIG. 27. In particular, at a step 2803, astart index is set to a value equal to the index for the current peakplus the minimum beat value. At a step 2806, an end index is set to avalue equal to index for the current peak plus the maximum beat counttolerance. In a step 2809, a search is then performed that identifiesall peaks between the start index and the end index. If no peaks werefound, as tested in a step 2812, the next peak value is accepted as avalid peak value in a step 2826 by incrementing the valid peak counter.If, however, peaks were found in step 2809, as tested in step 2812, anerror score for the current indexed peak is calculated in a step 2818.This error score is based on the distance from the expected next peaklocation and the scaled amplitude. The error score will be used todetermine which candidate peak to keep. In a step 2821, a determinationis made of whether any more peaks exist between the start index and endindex that need to have an error score calculated for them. If so,control passes to step 2818 and the next peak is processed. If no morepeaks exist that need to have an error score calculated for them, thecandidate unlisted peak with the smallest error value is retained in astep 2823. Control then passes at a step 2829 to FIG. 29.

FIG. 29 continues detailing the process of searching for unlisted peaks,according to one embodiment of the invention. In FIG. 29, the candidatepeak with the smallest error that was determined in step 2823 is furthertested. In a step 2902, a determination is made of whether the candidatepeak index is equal to the index value of the expected next peak. If so,the candidate peak is accepted in a step 2904 as a valid peak byincrementing the valid peak counter. If, however, the candidate peakindex is not equal to the index value of the expected next peak, furtherprocessing must be done prior to accepting the peak as a valid startpoint. In particular, at a step 2906, the duration corresponding to thecurrent peak is added to the duration corresponding to the next peak.The resulting sum is stored as the interval value corresponding to thecurrent peak. Next, in a step 2908, the peak that would be the nextexpected start point after the current and next peak (i.e., the currentpeak location plus two), is deleted from the start points table as aninvalid peak. Instead, the current candidate peak is inserted into thestart points table in a step 2910. In a step 2912, the remaining entriesin the start points table are adjusted. In an embodiment of theinvention, this adjustment consists of moving the remaining entries inthe start points table down by one entry and adjusting all appropriatepointers and counters (such as the incrementing of the deleted peakscounter in a step 2914 and the incrementing of the valid peak counter ina step 2916).

Referring back to the test in step 2702 of the flow chart in FIG. 27, ifthe duration from the current peak to the next peak is not within thebeat count tolerance (and that same duration is greater than the minimumbeat duration as tested in step 2604 of FIG. 26), control is passed atstep 2120 to FIG. 30, which further details the process shown in step2502 of evaluating each peak in the start point table.

In a step 3003, a start index is set to a value equal to the index forthe current peak plus the minimum beat value. At a step 3006, an endindex is set to a value equal to the index for the next peak location.In a step 3009, a search is then performed that identifies all unlistedpeaks between the start index and the end index. If no peaks were found,as tested in a step 3012, a peak edit counter (which keeps track ofpeaks which have been modified) is incremented in a step 3033 and thenext peak value is accepted as a valid peak value in a step 3036 byincrementing the valid peak counter. In one embodiment, a test is thenperformed in a step 3039 of whether the duration corresponding to thecurrent peak is greater than 225% of the beat duration estimate. If so,the error count is incremented in a step 3042.

If, however, unlisted peaks were found in step 3009, as tested in step3012, an error score for the current indexed peak is calculated in astep 3018. This error score is based on the distance from the expectednext peak location and the scaled amplitude. The error score will beused to determine which candidate peak to keep. In a step 3021, adetermination is made of whether any more peaks exist between the startindex and end index that need to have an error score calculated forthem. If so, control passes to step 3018 and the next peak is processed.If no more peaks exist that need to have an error score calculated forthem, the candidate peak with the smallest error value is retained in astep 3024. Control then passes at a step 3027 to FIG. 31, which furtherdetails the process shown in step 2502 of evaluating each peak in thestart point table.

FIG. 31 continues detailing the process shown in step 2502 of evaluatingeach peak in the start point table, according to one embodiment of theinvention. In FIG. 31, the candidate peak with the smallest error thatwas determined in step 3027 is further tested. In a step 3102, adetermination is made of whether the candidate peak index is equal tothe index value of the expected next peak. If so, the candidate peak isaccepted in a step 3104 as a valid peak by incrementing the valid peakcounter and incrementing the peak edit counter. If, however, thecandidate peak index is not equal to the index value of the expectednext peak, further processing must be done prior to accepting the peakas a valid start point. In particular, at a step 3106, the candidatepeak is inserted into the peak value table, and at a step 3108 the newduration, which is based on the current candidate peak, is inserted intothe duration array. Then, in a step 3112 the valid peak counter isincremented and in a step 3114, the peak edit counter is incremented.

Referring again to FIG. 25, after the peaks in the start point tablehave been evaluated, a test is then made at a step 2504 of whether thelast peak in the cardiovascular sound signals is too close to the end ofthe file of cardiovascular sound signals. If the last peak is too close,the last entry from the start point table and its corresponding durationis removed in a step 2506 and the peak value counter is decremented in astep 2508. In a step 2510 a parsing score is computed by subtracting 0.1for peak error and 0.01 for peak edits from a perfect score of one.

The preceding discussion of FIG. 23 through FIG. 31 described theprocess shown in step 2235 of FIG. 7, which are the steps, according toone embodiment of the invention, for parsing the cardiovascular soundsignals and extracting the start point of each heart cycle signal basedon the current convolution of the smoothed cardiovascular sound signalswith either the bootstrap filter (if the first time through the loopshown in FIG. 7) or the currently indexed beat (if not the first timethrough the loop).

A parsing score based on the parsing process is calculated in a step2240 of FIG. 6. In one embodiment, the parsing score is calculated as:parsing score=valid peaks/(number of peaks+error counter−1)−0.01(peakedit counter+deleted peaks counter)  [1]

Thus, the parsing score will only be equal to one where the number ofvalid peaks determined by the steps above is equal to the total numberof peaks chosen as candidate peaks (i.e., peaks above a predefinedthreshold), and also where the peak edits counter and deleted peakscounter are both zero (i.e., no edits were made to either the peaks orthe durations during the previously described steps of extracting thestart point of each heart cycle signal).

If, as a result of the parsing process discussed in the preceding steps,the predicted start point of each heartbeat interval aligns with all ofthe peaks shown in FIG. 22, a perfect parsing score of one results. Thecalculated parsing score is checked in a step 2245 of FIG. 7 against thecurrent best parsing score. If the parsing score is greater than thecurrent best parsing score, the current parsing score is made thecurrent best parsing score at step 2250. Next, the current best parsingscore is checked in step 2255 to determine if a perfect parsing score ofone has been calculated.

If the current best parsing score is not equal to a perfect parsingscore of one, then a check is made in step 2260 of whether there areadditional smoothed cardiovascular heartbeat cycle sound signals to beprocessed. If there are additional smoothed cardiovascular sound signalsto process, the index into the peak detect signal is updated to point tothe next predicted beat. This new beat is then convolved in step 2265with the smoothed cardiovascular sound signals in waveform 820 of FIG. 9to produce a new set of cross-correlation peaks. The loop describedabove consisting of step 2230 through step 2255 is then repeated until aparsing score of one is reached or there are no more peak detect signalsavailable.

If the current best parsing score is equal to one or if there are nofurther peak detect signals to process, a determination is made in step2275 of whether an incomplete beat exists at the end of the smoothedcardiovascular sound signals. If so, the incomplete beat is discarded instep 2280. Otherwise, the process continues without discarding anything.

If the highest parsing score of one is obtained from this search, thenthe relative phase of S1 in the best segment is measured and comparedwith that of the heartbeat average that matched the original waveformestimate. This establishes the S1 start point phase of the heartbeatsegment with the highest parsing score.

After all correlation searches are completed, the results from thesearch having the best parsing score are stored for the file underprocess. This table of data lists the starting indices of eachheartbeat. A table of the differences of adjacent start points iscalculated to provide the duration of each heartbeat interval.

An example of this table for 44 heart beats is shown in Table 3 below.TABLE 3 Heart beat start indices Example of the result returned fromPeak Analysis Parsing Score = 0.920 Number Syncs 44 Syncs and DurationArrays are in Narrowband Time Sample Points Beat Sync Duration 1 216 2972 507 285 3 795 301 4 1095 291 5 1398 297 6 1695 297 7 1987 287 8 2271292 9 2570 306 10 2867 279 11 3145 233 12 3381 348 13 3729 291 14 4023292 15 4313 277 16 4597 310 17 4901 290 18 5195 288 19 5482 274 20 5758311 21 6054 285 22 6339 287 23 6633 287 24 6913 280 25 7199 296 26 7494290 27 7786 276 28 8068 286 29 8353 307 30 8652 290 31 8946 276 32 9217285 33 9501 293 34 9805 305 35 10104 273 36 10379 288 37 10668 305 3810966 287 39 11256 276 40 11535 281 41 11813 309 42 12116 286 43 12408286 44 12688 273

Although the search results at this point are fairly accurate, inaccordance with one embodiment, further processing is carried out tofurther improve the results. For example, a Vernier fine tuning processcan be performed in a step 2285 that can improve the determined start ofeach heart cycle signal. The center of the convolution result can thenbe searched to see if even greater correlation occurs between therespective pulse waveforms, by shifting the subsequent peak detectedsignal by a slight shift along the time axis. If greater correlationdoes result, the start of the synch index for the next heart cyclesignal is then shifted by the correlation offset. This process isrepeated throughout the entire set of parsed heart cycle signals. Otherfine tuning processes could include comparisons of the onset of S1 orthe alignment of the peaks of S1.

As shown in the detail of FIG. 32, this Vernier fine tuning process canloop through each of the heart cycle signals convolving a section of thenarrowband time waveform from the current heart cycle signal with thenext heart cycle signal. In particular, at a step 3202 of FIG. 32, a setof variables are initialized and the peak values array is copied intolocal storage for the Vernier tuning process. In a step 3204, the startand end limits for the currently indexed heart cycle signal aredetermined and in a step 3206, the start and end limits for the nextheart cycle signal are determined. In a step 3208, the S1 region of thecurrently indexed heart cycle signal is convolved with the next heartcycle signal. In a step 3210, a maximum correlation value is determinedin a previously determined Vernier limit region around the center of theconvolution result and a corresponding delta shift value is determined.If the delta shift value is less than a previously defined limit, astested in a step 3212, then the next peak value is shifted by the deltashift value in a step 3214. If the delta shift value is not less than apreviously defined limit, a determination is made in a step 3216 ofwhether there are more beats to process. If so, the beat index isupdated in a step 3218 and control passed back to step 3204.

As an interim summary, the above described process of determining thestart point of each heart cycle signal within the acquiredcardiovascular sound signals (as depicted in FIG. 6 through FIG. 32) issummarized in the input/output detail in FIG. 33. Specifically, with aninput autocorrelation of the filtered and smoothed heart audio signalsshown in signal 3310 in FIG. 33, a math model filter such as the oneshown in signal 3320 can result. Similarly, when the math model filterand bootstrap filters have been determined, they can be used toestablish the start point locations of the heart cycle signals, asdepicted in signal 3330 of FIG. 33.

Determine Start or End of Heartbeat Phases

Referring back to FIG. 5, once the start point of each heart cyclesignal has been determined in step 2200, a determination is then made ina step 2400 of a start point and/or end point of one or more of thephases of each heart cycle signal, including S1 and S2, preferablyincluding S1 through S4. In one embodiment, the parsing of thecardiovascular sound signals and the identification of the phases ofeach heart cycle signal occurs without a separate reference signal, suchas an ECG, that indicates the start of a heart beat. As described above,four intervals, S1, S2, diastole, and systole, are associated with eachheartbeat cycle, as reflected in each heart cycle signal. Averagemeasurements of these intervals are used in subsequent processing, asdescribed below. The measurement of these intervals is depicted in theflowchart shown in FIG. 34.

All of the heart cycle signals in the filtered cardiovascular soundsignals (a portion of which is shown in FIG. 46) are summed in a step3402 of FIG. 34 to build an average envelope that emphasizes S1 and S2.In particular, as further detailed in step 3502 of FIG. 35, the averageenvelope calculation begins with a determination of the number of heartcycle signals from the start points table. In a step 3504, an averageenvelope is initialized, in one embodiment, to all zeroes. Likewise, inthat same step an index into the smoothed cardiovascular sound signalsis determined. Using the start point information from the start pointstable, each point from the currently indexed heart cycle signal getsadded into the average envelope. In a step 3508, the index into thestart points table is updated and a determination is made in a step 3510of whether any more heart cycle signals need to be added to the averageenvelope or if the averaging portion of the process is done.

In a step 3404 of FIG. 34, the average envelope is filtered to enhancethe frequencies most prevalent in the S1 and S2 pulses. Thesefrequencies typically range from 20 Hz to 60 Hz. As shown in the detailsof step 3404 that are shown in FIG. 36, a low pass finite impulseresponse (FIR) filter is created in a step 3602 and convolved againstthe smoothed cardiovascular sound signals in a step 3604 to create aphase window. In a step 3606, the low pass filter offset from the phasewindow is stripped out (i.e., the widening caused by the low pass filterprocess). Waveform 4810 of FIG. 48 shows the audio waveform after thelow pass filtering and convolution process used to enhance S1 and S2.

Once the phase window has been calculated, a second derivative of thephase window is calculated in a step 3406 to determine whether theextrema in the phase window are positive (i.e., peaks) or negative(i.e., valleys). After the peaks and valleys are determined, theexpected peak locations in all of the heart cycle signals are computedin a step 3408. The expected peak locations for S1 and S2 are calculatedrelative to the average beat duration and previously measured S1 to S2spacing.

FIG. 37 provides further detail on the peak/valley determination of step3408. In a step 3702 of FIG. 37, all peak values in the phase window aredetermined and identified. In a step 3704, those peak value locationsare normalized by, in one embodiment, subtracting the minimum power inthe phase window. Next, in a step 3706, nominal offsets for the S1 andS2 peaks are computed. In one embodiment, the S1 offset is calculatedfrom the index of the first occurrence of S1 in the start points table.The S2 offset is then calculated based on the S1 offset, and is limitedto be within the first half of the computed beat duration estimate.Finally, in a step 3708, an array of nominal locations for the S1-S4peaks is built, based on the nominal offsets calculated in step 3706.

Referring back to FIG. 34, a determination is made in a step 3410comparing the actual peak locations to the predicted peak locations, andgenerating a score for each predicted peak location. The best scores foreach S1 through S4 candidate peak are then used to assign the actualpeak locations.

FIG. 38 provides further detail on the peak location and scoringprocesses of step 3410 of FIG. 34. In a step 3802, a peak location arrayis initialized for tracking the S1 to S4 locations in the phase window.In a step 3804, a score for each nominal S1 to S4 peak location iscomputed, based on the power at that nominal location. In a step 3806, acomparison is made between the score for each nominal location and thescore for the normalized power of all peaks. If the score for thenominal location is less than the normalized power for the actual peaklocation (as checked in a step 3808), then the S1 to S4 peak locationarray entries are updated with the location of the peak with the highervalue.

In a step 3812, a determination is made of whether any of the S1 to S4peak location array entries are empty. If so, those empty peak locationarray entries are populated. In one embodiment, they can be filled withpredetermined values. In another embodiment, they can be populated withvalues extrapolated from other populated locations.

In a step 3412, all of the valley locations in all of the heart cyclesignals are determined in a fashion similar to the determinations of thepeak locations. The identification of all of the phase intervals for allof the heart cycle signals in a heart waveform (or heart cycle signal)consists of computing the approximate regions of S1 through S4 based onthe peaks and valleys identified in the preceding steps. If the peaksand valleys were not able to be properly identified, an estimate of theregions is made, relative to the average beat duration for the currentheart waveform.

FIG. 39 provides further detail on the valley location and scoringprocesses of step 3412 of FIG. 34. In a step 3902, a valley locationarray is initialized for tracking the S1 to S4 locations in the phasewindow. In a step 3904, a score for each nominal S1 to S4 valleylocation is computed, based on the power at that nominal location. In astep 3906, a comparison is made between the score for each nominallocation and the score for the normalized power of all valleys. If thescore for the nominal location is less than the normalized power for theactual valley location (as checked in a step 3908), then the S1 to S4valley location array entries are updated with the location of thevalley with the higher value.

FIG. 40 then provides further detail on step 3414 shown in FIG. 34,depicting the phase interval assignment for each heart cycle signal. Instep 4002 through 4008, the indices for each of the S1 through S4regions is determined for all heart cycle signals in the file containingthe cardiovascular sound signals.

FIG. 41 depicts the process in step 4002 of FIG. 40 by which the S1indices are determined. In a step 4102, the S1 region indices areinitialized. At step 4104, a determination is made of whether a peakwith a following valley was found, based on the values in the peak andvalley locations arrays. If no such peaks with following valleys aredetected, the S1 region indices are assigned based on the nominallocation of the S1 peak at a step 4118. If, however, peaks withfollowing valleys were detected, an amplitude threshold value iscomputed in a step 4106. Then, in a step 4108, the first and last indexvalues in the phase window that are greater than the amplitude thresholdvalue are determined. If both such indices are found (based on a test ata step 4110), the S1 region start index is set equal to the first indexvalue in a step 4112 and the S1 region end index is set equal to thelast index value in a step 4114. If both such indices were not found instep 4110, the S1 region indices are assigned in a step 4116 based onthe beat duration estimate calculated earlier, as would be apparent.

Similar to the process in FIG. 41, FIG. 42 depicts the process in step4004 of FIG. 40 by which the S2 indices are determined. In a step 4202,the S2 region indices are initialized. At step 4204, a determination ismade of whether a peak with a following valley was found, based on thevalues in the peak and valley locations arrays. If no such peaks withfollowing valleys are detected, the S2 region start index is assignedbased on the nominal location of the S2 peak at a step 4218. At a step4220, the S2 region end index is assigned based on the zero crossingfrom the S2 peak to the following valley, as would be apparent.

If peaks with following valleys were detected in step 4204 of FIG. 42,an amplitude threshold value is computed in a step 4206. Then, in a step4208, the first and last index values in the phase window that aregreater than the amplitude threshold value are determined. If both suchindices are found in the test at a step 4210, the S2 region start indexis set equal to the first index value in a step 4212 and the S2 regionend index is set equal to the last index value in a step 4214. If bothsuch indices were not found in step 4210, the S2 region indices areassigned in a step 4216 based on the nominal location of the S2 peak.

Once the S1 and S2 phase indices have been determined as detailed above,the S3 and S4 phase can also be determined. If the S3 peak is missing,the start of the S3 phase location is assigned based on the location ofthe valley between the S2 peak and the third peak. The mid point of theS3 phase is determined from the first point to be ¾ in value of theleading edge of the 3^(rd) peak. Similarly, if the s4 peak is missing,the start of the S4 phase location is assigned using the startinglocation of the 4^(th) peak.

To illustrate the above process, FIG. 47 shows the results of theparsing operation that causes the windowing of the S1 and S2 heartpulses. FIG. 47 also shows weak signals at 0.7 and 0.82 seconds, whichare S3 and S4 pulses common in many patient's heartbeat.

Heart Pulse Statistics

Once the start points of the heart cycle signals are found, and thecorresponding phases have been assigned, data can be accumulated on theindividual pulse data found within each heartbeat. In particular, thestart, duration and relative power in all individual pulses can befound. Pulses are then assigned for S1 through S4 according to thepreviously determined phase assignment.

The actual the start and end points of all of the S1-S4 heart pulses inthe heart cycle signals are next determined in step 3416 of FIG. 34. Theprocess of finding the pulses locates those points in the waveform thatare above a pre-defined threshold, as follows. The flow chart shown inFIG. 43 depicts the process of identifying the start and end points ofthe S1-S4 heart cycle signals. The process begins by smoothing outunwanted high frequency components of the heart audio. To do so, thenarrow band waveform described earlier is band-pass filtered in step4302 with a center pass-frequency of 40 Hz and 3 dB skirts at 20 and 60Hz. Also in step 4302, the filtered waveform is transformed by anabsolute value function. In a step 4304, the locations of all peaks andvalleys in the signal computed in step 4302 are identified and stored,followed by the identification of the maximum peak value in a step 4306.

In a step 4308 a number of additional threshold parameters aredetermined. The threshold parameters consist of, in one embodiment, themaximum number of beats in the cardiovascular sound signals, a gap runtime (which is the minimum length in seconds of the gap between thepulses), the pulse length threshold (which is the minimum acceptablelength in seconds of pulses), a minimum pulse count (which is theminimum number of pulses to search to locate the S1 to S4 pulses), anamplitude threshold (which is the fraction of the maximum signal toconsider), a minimum amplitude threshold, a threshold step value, and aminimum threshold step value.

In one embodiment, an initial amplitude threshold is set equal to avalue that is one quarter of the maximum peak in the waveform. Indefining valid pulses in one embodiment, they have a duration greaterthan 0.035 seconds. Additionally, individual pulses separated by lessthan 0.055 seconds are combined as one pulse. This forces a connectionfor the positive and inverted negative segments of the pulse.

Since a typical heartbeat has an S1 and S2 pulse, and may have S3 and/orS4 pulse, the search algorithm generally tests to see whether the pulsecount is at least four times the number of heartbeats in the sample. Ifthe pulse count is insufficient, then the amplitude threshold is lowereda small amount and a new set of pulses is extracted. This process willcontinue until an amplitude threshold limit is reached or the pulsecount decreases by a predetermined amount. The limit is set to avoidextracting noise pulses.

In particular, as shown in FIG. 44, the S1 to S4 pulse determinationprocess commences with a pulse array being initialized in a step 4402.This array will, upon completion of the process, contain indices forthose S1 to S4 pulses that were identifiable in the heart cycle signals.In a step 4404, an adjustment is made for any gaps that might exist atthe beginning or end of the absolute value narrowband cardiovascularsound signals. Next, any peaks that are greater than a peak (or clip)threshold are isolated in a step 4406. In a step 4408, a determinationis made of whether the current run length is greater than apredetermined run length threshold. Specifically, a run length isdefined as the amount of time during which a set of peaks that make up apulse remain greater than the run length threshold.

Once all of the run lengths above the run length threshold have beendetermined, a check is made to determine whether the run lengths can beconsidered as actual S1 to S4 pulses. To begin, a pulse count isinitialized in a step 4410. In a step 4412, an offset is added to thebeginning and end of each run length. In one embodiment, this offset isset equal to one quarter (25%) of a typical or nominal 25 Hz heartcycle. The offset is added to account for the fact that a pulse actuallybegins approximately one quarter of a cycle before the first peak andfinished approximately one quarter of a cycle after the last peakfinishes.

After adding the offsets in step 4412, a test is made in a step 4414 ofwhether the duration of the adjusted pulse is greater than thepredetermined pulse length threshold. If so, a In a step 4418, adetermination is made of the power of the pulse by summing the power ofeach peak that comprises the pulse. Again referring to FIG. 47, an S1pulse of one heart cycle signal is shown framed at about 0.2 seconds andan S2 pulse of what is presumed to be the same heart cycle signal isshown framed at approximately 0.5 seconds. The pulse power determinationjust described would entail summing the power for each of the peakswithin those framed pulses.

In a step 4420, the pulse counter is incremented and in a step 4422, atest is made of whether there are further run lengths to process. Ifthere are further runs to process, control passes back up to step 4412where the next run is processed. If there are no further runs toprocess, a test is then performed in a step 4424 of whether the currentpulse count is less than the predetermined minimum pulse count.

If the current pulse count is less than the minimum pulse count at step4424, the amplitude threshold is updated on the expectation thatadditional peaks will then be detected as part of one or more runlengths, thereby increasing the pulse count. To update the amplitudethreshold in one embodiment, the amplitude threshold is firstdecremented by the threshold step in a step 4426. The threshold step isthen updated by reducing it by 10% in a step 4428. A test is then madein a step 4430 to determine if the threshold step is less than thethreshold step minimum. If the threshold step is less than the thresholdstep minimum (meaning that a suitable number of peaks has not been foundeven though the threshold step has been reduced to its minimum value),the threshold step is set equal to the minimum threshold step value in astep 4432.

At a step 4434, a test is made to determine whether the current pulsecount is less than the previous pulse count minus four. This test ismade to account for split S1 and S2 pulses which may disappear as theamplitude threshold is reduced. In particular, the gaps between thecomposite peaks at higher amplitude that make up an S1 or S2 signal maygo away when the amplitude threshold is lowered. If the current pulsecount meets the test (i.e., a previous amplitude threshold valueproduced as good as or better results than the current amplitudethreshold value, the amplitude threshold is forced to the minimumamplitude threshold (which will cause an early exit from the processingloop at a step 4442.

If the current pulse count is acceptable at step 4434, control passes toa step 4438. In one embodiment, once a suitable pulse count is obtained(or the amplitude limit is reached) the pulse start, pulse end, andtotal pulse power are logged in the pulse table in step 4438. Therelative power is calculated from the square of the sum of the samplevalues across the pulse. In an alternative embodiment that involvesancillary pulse data (described in FIG. 45), the pulse start, pulseduration, and pulse power are determined as shown in Table 4 below,which contains the first seven entries of an exemplary pulse table.TABLE 4 PULSE TABLE Pulse Start Duration Power 1 70 50 64 2 205 42 83 3428 60 166 4 559 35 87 5 775 65 162 6 914 44 79 7 1134 46 68

Referring back to FIG. 44, a determination is next made at a step 4440of whether the current pulse count is less than a predetermined minimumpulse count. If so, a test is then performed at step 4442 to determinewhether the current amplitude threshold is greater than the minimumamplitude threshold. If both of these tests are true (i.e., a minimumnumber of pulses has not yet been determined and the amplitude thresholdis not at its minimum value), control returns to step 4404 with alowered amplitude threshold value. Otherwise, the process completes.

Given the pulse table shown in Table 4 above and the heartbeat phaseinformation determined in step 3414 and step 3416 of FIG. 34, each pulsecan be assigned a phase within the heartbeat. The assignment algorithmchecks the location of the start of the pulse within a given heartbeatand determines whether the pulse overruns into the next heartbeat phase.If the overrun is excessive, then the pulse is split to report pulseenergy from two or more phases according to the extent of the pulse.Often an S4 pulse will merge with the S1 pulse of the next heartbeat.

The tabulated data for nine heartbeats of the heart audio example usedhere are listed in table 5 below. Only two weak S4's were found and noS3's are reported. The pulse-start referenced to the start of theheartbeat and pulse-duration are reported in units of the narrow bandSample Index TABLE 5 HEARTBEAT DATA: HEARTBEAT PULSES - TIMES IN SAMPLEINDICES Start S1 S2 S3 S4 Beat Index Duration Strt Dur Pwr Str Dur PwrStrt Dur Pwr Strt Dur Pwr 1 62 360 8 50 64 143 42 83 0 0 0 0 0 0 2 422352 6 60 166 137 35 87 0 0 0 0 0 0 3 774 351 1 65 162 140 44 79 0 0 0 00 0 4 1125 359 9 46 68 145 33 84 0 0 0 0 0 0 5 1484 355 7 50 69 142 4275 0 0 0 319 16 12 6 1839 343 2 65 187 138 34 86 0 0 0 0 0 0 7 2182 3393 58 159 140 26 67 0 0 0 0 0 0 8 2521 344 6 53 130 145 35 65 0 0 0 0 0 09 2865 339 6 53 85 148 30 51 0 0 0 290 19 14

Statistics on the start and end points (and associated intervals) aredetermined in a step 3418 of FIG. 34. In an embodiment (as illustratedin the flowchart shown in FIG. 45), such statistics can include pulseduration and pulse power. At a step 4502 in FIG. 45, a set of parametersis initialized. In one embodiment, such parameters can include anoverrun threshold set to 5% of the beat duration estimate, a newduration threshold, and a counter of the number of start points. At astep 4504, the start time of the first pulse of the current heart cyclesignal is checked to determine if it is before the start point of thatheart cycle signal. If so, a check is then performed at a step 4506 ofwhether the index of the end of the pulses for the current heart cyclesignal minus the start point for the current heart cycle signal isgreater than the overrun threshold. If so, the current pulse isredefined in a step 4508 to fit in the current heart cycle signal. Thena check is made in a step 4510 if any more pulses need to be processedand, if not, whether any more heart cycle signals need to be processedin a step 4512.

If the index of the end of the pulses for the current heart cycle signalminus the start point for the current heart cycle signal is not greaterthan the overrun threshold (as tested in step 4506), then the currentpulse is determined to be a leading pulse not in the parsed set ofheartbeats and is discarded in a step 4514. Control then passes to step4510, where a check is made of whether any more pulses need to beprocessed and, if not, whether any more heart cycle signals need to beprocessed in a step 4512.

If the start time of the first pulse of the current heart cycle signalis not before the start point of that heart cycle signal (as checked instep 4504), a check is then made in a step 4516 of whether the starttime of the current pulse is within the current heart cycle signal. Ifso, the S1 through S4 phase values are associated based on thepreviously assigned phases in a step 4518. Then, in a step 4520,appropriate adjustments are made due to any overruns into subsequentphases.

If the start time of the current pulse is not within the current heartcycle signal (as checked in step 4516), the current pulse is split intoappropriate S1 to S4 components using the previously determined phaseassignment indices. This case covers the situation where the start timeof the current pulse is in the next heartbeat.

FIG. 48 and FIG. 49 provide further information on the process describedabove for determining the start points and end points of one or morephases of each heart cycle signal, according to an embodiment of theinvention. Chart 4810 in FIG. 48 depicts the phase window signal that isused as a more precise estimate of the location of the S1 and S2 phasesacross all heart cycle signals. With the filtered narrowbandcardiovascular sound signals as input, in combination with the phasewindow in chart 4810, array 4820 is produced, which shows thegeneralized 11 through S4 regions for all heart cycle signals.

FIG. 49 contains an exemplary pulse array 4910 (similar to that shown inTable 4) that includes a pulse index, pulse start value, pulse lengthvalue, and a pulse power value. FIG. 49 also contains pulse statisticsarray 4920 showing the ancillary pulse data information for eachheartbeat (similar to the data shown in Table 5).

Identify Bruit Candidates

Referring again to FIG. 4, after the acquired cardiovascular soundsignals have been parsed at step 2000, bruit candidates are identifiedfrom high frequency anomalies at a step 3000. In one embodiment, thesystem identifies bruit candidates that occur in the diastolic interval.In another embodiment, the below described processing is similarly usedto identify bruit candidates in systole. In yet another embodiment, theprocess described below with respect to step 3000 can be used toidentify bruit candidates in the background noise signals, which canthen be used in the noise cancellation process described further below.

Generally speaking, at step 3000, in the illustrated embodiment of thesystem 100, the processing algorithm seeks anomalies in the acquiredcardiovascular sound signals, such anomalies being defined as havingpeak energies in the 300 to 1800 Hz frequency bands. As will bediscussed in further detail below, anomalies meeting certain predefinedcriteria will be identified as bruit candidates. In the case of coronaryartery disease, these identified bruit candidates are believed to beindicative of blockages in coronary arteries.

FIG. 50 shows one heartbeat with a magnified view of bruits occurring indiastole, which are indicated by three bursts of high frequency energyat approximately 8.54, 8.63, and 8.75 seconds. Signals such as these arenot normally seen from patients without heart disease.

Flowchart 3000 in FIG. 51 illustrates the process of identifying bruitcandidates in each heart cycle in one or more heart waveforms of theacquired cardiovascular sound signals. In order to identify bruitcandidates, all cardiovascular sound signals with peak frequencycomponents in the 300 to 1800 Hz band are logged and weighted toparticipate in a final probability of repetitive bruits. A set of bruitdetection parameters has been defined and adjusted to screen out anyanomalies not necessary for the process. The primary bruit detectionparameters are listed below along with a brief description of theirpurpose. Their use will become clearer in the discussions to follow.Parameter Description Value NoiseAvgWindowFact Fractional HeartbeatPeriod 1.0 for Spectral Averaging SkewCutoffThreshold Anomalies withgreater Skew 0.75 are ignored BruitDetectionThreshold Anomalies withless spectral 14.0 dB HA energy are ignored - Heart AudioBruitDetectionThreshold Anomalies with less spectral 11.5 dB BN energyare ignored - Background Noise LowFrequencyLimit Low Frequency limit 300Hz HighFrequencyLimit High Frequency limit 1800 Hz FFTSize Size of FFTin wideband 128 sample points SpectrumOffset Spectrum overlap ratio 0.5MeanTimePowerThreshold Time data energy rejection 0.96 HA threshold -Heart Audio MeanTimePowerThreshold Time data energy rejection 0.49 BNthreshold - Background Noise Spectrum Notch Width of spectrum rejection2205 Hz Threshold HA zone in Hertz around located bruit candidate: HeartAudio Spectrum Notch Width of spectrum rejection 400 Hz Threshold BNzone in Hertz around located bruit candidate: Background NoiseFreqSepLim Noise cancellation frequency 1200 Hz separation limit

FIG. 51 illustrates the processing used to detect bruit candidates ineach heart cycle. The characteristics of bruits are such that they aredistinguishable by measurements made in the frequency domain. Theultimate goal of deriving the probability of bruits in diastole beginswith spectral measurements of the cardiovascular sound signals. In orderto suppress any transient effects from segments of low frequency signalenvelopes, the cardiovascular sound signals are first high passfiltered. In an embodiment, frequencies from 300 Hz and up are retainedwhile those below 200 Hz are heavily attenuated.

Each filtered heart cycle signal is then segmented into nominal 15millisecond intervals (also known as windows or segments) forevaluation. In one embodiment, each heart cycle signal is processed innumerous sample sets each having 128 time samples from the data sampledat 4.4 kHz. Each of the sample sets is nominally 30 milliseconds induration. Successive spectra (frequency and magnitude) are calculatedfrom sample sets that overlap adjacent sample sets by 64 time samples.The use of a binary number of time samples (e.g., 128) enables the useof Fast Fourier Transform or other processing to expedite calculation ofthe spectra. A windowing function (such as a Blackman or Kaiser Window)is applied to each sample set to suppress the contribution of timesamples at the beginning and end of each sample set. The windowingsuppresses sample edge transients that can corrupt the resultantspectrum. Further, the spectrum for each time window or segment, thoughcalculated over a time window nearly 30 milliseconds wide, favors onlythe signals from the central 15 milliseconds. FIG. 64 graphicallyillustrates a representation of this segmenting across a portion of aheart cycle having a bruit candidate. The mean time data energy sum ofeach FFT time window is computed in the process described above for FIG.51 through FIG. 55.

More specifically, as shown in FIG. 51, bruit candidates in the widebandheart audio signal for each heart beat cycle signal are detected in astep 5120. As discussed in further detail below with respect to FIG. 52through FIG. 60, to detect bruit candidates, the spectrum of each15-millisecond time window within systole or diastole, normalized by theratio to a noise floor, is inspected to see if any spectra have cellswith an energy ratio above a bruit power detection cutoff. If found, themean time data power for the spectrum window is compared to a mean timepower threshold. If it is greater than the mean time power threshold,the skew ratio is computed. If the skew ratio is less than a skew cutoffthreshold, the bruit candidate's time coordinate, the frequency of thespectral peak of the bruit candidate, and the ratio of the bruitcandidate spectral power to the local spectral average (SNR) areinserted into the bruit candidate table. A search for multiple bruitcandidates can be made within each spectrum slice.

In one embodiment, a heart waveform includes a number of heart cycles,where the heart waveform was sensed at one location on a patient. Asillustrated by step 5120 of FIG. 51 and the steps in FIG. 52, the heartaudio waveform is run through steps 5202 through 5206 to identify bruitcandidates in each heart cycle signal. In accordance with a preferredembodiment, this process is repeated for each heart cycle of each heartaudio waveform sensed at each of the nine previously describedlocations. As mentioned above and described below, the informationcollected on each bruit candidate, is entered into a table in step 5208of FIG. 52.

FIG. 52 provides further detail on the process in step 5120 of detectingbruit candidates. At a step 5202, a table of skew normalization factorsis created that is a function of the frequency index of the amplitudepeak of the bruit spectrum. FIG. 53 is a flowchart depicting the detailsof the process in step 5202 of creating a table of skew normalizationfactors, as part of the overall process of detecting bruit candidates.In particular, at a step 5302, a low frequency index is determined basedon the size of the FFT to be used in the process and a predetermined lowfrequency limit. Similarly, at a step 5304, a high frequency index isdetermined based on the size of the FFT to be used in the process and apredetermined high frequency limit. At a step 5306, a counter is set tothe value of the low frequency index. Entering a loop at a step 5308, adetermination is made of whether the current counter is greater than thehigh frequency index. At a step 5310, the skew normalization factor iscomputed for the filter index in the spectral frequency range. The skewnormalization computation is discussed in greater detail in thedescription of the skew ratio processing below. The process is repeatedfor all indexes in the spectrum frequency search range as shown in astep 5308 and 5312.

At a step 5204 in FIG. 52, a normalized and averaged 2 dimensionalspectrum array is generated from the high pass filtered time signal.FIG. 54 is a flowchart depicting the details of the process in step 5204of creating a table of frequency amplitude ratios that form a normalizedpower spectra array set, as part of the overall process of detectingbruit candidates. In particular, at a step 5402, the wideband audiosignals are band pass filtered and put into a time array. At a step5404, a spectra slice array is generated for the entire time array. Thisproduces a spectral value for each time segment of nominal width.

FIG. 55 provides further detail on the process of generating the spectraslice array, as shown in step 5404 of FIG. 54. In a step 5502, thenumber of spectra to calculate is determined, based on the length of thewideband cardiovascular sound signals and the size of the FFT. In oneembodiment, the number of spectra to calculate is equal to one less thantwo times the length of the time array data divided by the size of theFFT. At a step 5504, a Kaiser window is computed of a length equal tothe size of the FFT. In a step 5506, a spectrum counter is initializedto 0. At a step 5508, a decision is made about whether the spectrumcounter is equal to the number of spectra to be determined. If so, theprocess completes. If not, the process continues at a step 5510, whereinFFT indices are computed based on the spectrum counter, the spectrumoffset, and the FFT size. In one embodiment, the FFT size is 128. Next,in a step 5512, an FFT for the current time slice is calculated. In anembodiment, the FFT is calculated on the product of the Kaiser windowand the time array. After calculating the FFT, the amplitude spectrum isstored in a step 5514 and the time data sum for each spectrum slice iscalculated in a step 5516. In a step 5518, the spectrum counter isincremented and control returns to step 5508.

Once the raw spectral measurements have been made as described above,additional measurements are made to isolate high frequency anomalies ofinterest. These anomalies are isolated by comparing normalized spectralenergy measurements at each 15-millisecond interval with pre-definedfrequency and energy thresholds. The amplitude comparison is invariantto the scaling of the input signal amplitude. That is, variations in thegain settings at the time of the recording do not affect the results ofa bruit detection process. This is accomplished by replacing the rawspectral measurements with their ratios to the local spectral average.Since the local spectral average is typically a noise floor, theseratios, or Signal-to-Noise Ratios (SNR), are not overly sensitive to theamplitude level of the input waveform. As described in further detailbelow, local spectral averages are computed by averaging the signalacross each spectrum filter frequency over a Kaiser-Bessel or similarwindow that is a fraction of the duration of the heartbeat. The centralportion of the window is set to zero to suppress contribution from theactual signal. In one embodiment, the noise averaging window factor isone mean heart cycle duration. Since detection is dependent upon apre-defined SNR, extraneous background noise in the heart audio channelis preferably kept to a minimum so as not to suppress the bruitdetection sensitivity.

The set of normalized spectra calculated for the heartbeat shown in FIG.50 is exhibited in FIG. 65. Spectral amplitude is indicated in FIG. 65by the gray scale plot in which black corresponds to negligibleamplitude; while increasing amplitudes are correspond to lighter shades.Note that three bruits manifest themselves as relatively strong burstsof energy with peak frequencies just above 800 Hz and having durationson the order of 30 milliseconds. Energy on the far right of the plot isassociated with high frequencies of the S1 pulse of the next heartbeat.

Referring back to FIG. 54, in a step 5406, spectral averaging isperformed to eliminate any constant frequency noise, thus producing anaveraging window. FIG. 56 provides further detail on the process ofperforming spectral averaging and producing an averaging window. In astep 5602 in FIG. 56, a spectra scale factor is determined from thespectrum size. In one embodiment, the spectra scale factor is set equalto ten divided by the spectrum size. In a step 5604, the width of theaveraging window is computed based on the mean heart beat duration andin a step 5606 the averaging window is computed. In one embodiment, thisconsists of setting up a Kaiser-Bessel window that rolls to −10 dB atthe margin. In a step 5608, a determination is made of whether theaveraging window has a width of five or more. If so, the central threepeaks of the averaging window are set to zero in a step 5610. Otherwise,only the central peak is set to zero in a step 5612. In both cases, thesetting of the central peak or peaks to zero will avoid the suppressionof peaks that could occur when performing subsequent convolutions. In astep 5614, the averaging window is normalized to a value of one.

The averaging window described above is used in a step 5408 in FIG. 54.In that step, each spectral slice array is convolved against theaveraging window produced in step 5406. Further detail on this processis shown in the flow chart of FIG. 57. In a step 5702 a zero phaseoffset is determined based on half of the width of the averaging window.In a step 5704, a spectrum array counter is initialized to a value ofone, in one embodiment. In a step 5706, the spectrum array at afrequency index kk is convolved against the averaging window by steppingthrough the frequency cells to produce a windowed spectrum array set. Ina step 5708, the local spectra average is copied to a new 2 dimensionalspectrum array starting at the zero phase offset index. In a step 5710the spectrum array counter is incremented. A test is then made at a step5712 of whether any more convolutions are to be calculated. If so,control passes to step 5706; otherwise the process completes.

Next, in a step 5410 shown in FIG. 54, the spectra are normalized asratios to the local noise floor. In an embodiment, the normalizationinvolves dividing the raw spectra value by the average spectral valuesfor the frequency of interest. After normalization, the maximum value ineach spectral slice is determined in a step 5412.

Referring back to FIG. 52, at a step 5206, the spectrum slice indexsearch limits are computed from the frequency search limits and bruitdetection power thresholds are computed from their dB thresholds. FIG.58 provides details on the computation of these limits and thresholds.In steps 5852 to 5860, the bruit search ranges (in units of spectrumindices) are computed for the start and duration of each parsed heartbeat cycle in the time data. In a step 5852, the start and durationindex arrays for each beat are initialized to zero for the number ofbeats detected. In a step 5854, the beat index k is initialized to one.In a step 5856, the spectral index for the start of each heart beatcycle is computed from the time sample index stored in the synchs array.In a step 5858, the spectral index count for the duration of each heartbeat cycle is computed from the time sample count stored in the durationarray. In a step 5860, this process is repeated until indexes for allthe parsed beats have been computed. In a step 5862, the spectral indexoffsets for the S1 and S2 phase boundaries locations are computed fromthe S1 and S2 phase index table. In the steps 5864 through 5868, a timepower sum threshold is computed to be used in the bruit detectionprocess to filter out false weak time signal candidates. In a step 5864,the total sum of the time power measurements made for each spectrumslice which falls in the bruit search ranges is computed. In a step5866, the mean time power measurement is computed by dividing the totalsum by the number of spectrum slices in the bruit search ranges. In astep 5868, the time power threshold is computed by multiplying the meantime power measurement by the threshold parameter.

At a step 5208 in FIG. 52, the processed spectrum array is searched forbruit candidates for each detected heart beat cycle in the signal data.

As shown in FIG. 59, in a step 5802, counters and indices for the bruitcandidate table creation are initialized. A loop begins at a step 5804,in which both the systolic and diastolic intervals are scanned for asingle heat beat cycle signal and any detected bruit candidates areentered into the bruit candidate table. In step 5804 the systolicinterval is scanned, and in step 5806 the diastolic interval is scanned.

FIG. 60 provides further detail on the scanning process for bruitcandidates used in step 5804 and 5806 shown in FIG. 59. At a step 5902,a determination is made of which interval is to be scanned for theselected heat beat cycle. If scanning the systolic interval, thesystolic search limits are set in a step 5904; if scanning the diastolicinterval, the diastolic search limits are set in a step 5906. In bothcases, the search limits are the set by the start and duration of theselected heat beat along with the measured S1 and S2 heart phase indicesscaled to the indices of the spectral content of the wide bandcardiovascular sound signals. The systolic search interval is from theend of the S1 component to the start of S2. The diastolic searchinterval is from the end of the S2 component to the end of the selectedheart beat.

Once the search limits have been set, the peak spectral component ineach spectral slice that are greater than the bruit power detectionthreshold are determined and stored in a initial bruit candidate arrayin a step 5908. Based on the results of step 5908, a test is performedin a step 5910 of whether any bruit candidates were found. If not, noinformation is entered into the bruit candidate table and the processexits.

If initial bruit candidates were found, a loop is entered that processeseach initial bruit candidate. The first test in the loop is performed ina step 5912 of whether the time energy sum of the spectrum slice for thecurrent candidate is above the previously computed threshold. If not,control passes to a step 5930 to see if further bruit candidates in theinitial table are to be processed. If the time sum for the current bruitcandidate is above a predetermined threshold, the spectral segment thatcontains the bruit candidate is scanned in a step 5914 for all separatedpeaks that are above the bruit candidate power detection threshold. Thecandidate peaks must be separated in frequency by a minimum spectrumnotch threshold parameter which may be a different value for processingthe heart audio or background noise signal.

Each candidate peak in the current spectral segment is then tested in astep 5916 for whether the peak is greater than the bruit power detectionthreshold. If not, control passes to step 5926 to determine whetherthere are more candidate peaks in the current spectral segment. If so, askew ratio is calculated in a step 5918. Tests are then performed insteps 5920 and 5922 on the skew ratio to determine whether the peak hasa skew ratio below the skew threshold and Whether the peak is a truefrequency peak in the original spectrum (and not a false maximum valuepeak at the margin on a slop at the edge of the spectrum filter searchrange).

A second class of high frequency anomalies, known as clicks, has beenobserved in younger patients who have no known heart problems. Thesesounds with wide band spectral energies are preferably suppressed in theidentification of bruit candidates by properly setting the skewthreshold. If an anomaly satisfies the frequency and energy thresholds,an additional measurement is calculated to distinguish the clicks frombruits candidates.

To distinguish clicks from bruits, a discriminant is run based upon the‘skew’ of the spectral energy. Skew is the second moment associated withthe spectral distribution of energy around a frequency bin with the mostenergy. Given the frequency bin with the highest energy, then asimplified calculation of a skew parameter for the spectrum is made asfollows:Skew=sum(SpectRatio(j)*((j−peakindex)ˆ2))/(Normalization*PeakSpecRatio)  [2]

for j=low filter index to high filter index

where Normalization=sum(j)−peakindex)ˆ2)

for j=low filter index to high filter index

Note that if most of the energy of the spectrum is in the peak frequencybin, the value for skew approaches zero; if all the frequency bins havethe same energy as the peak filter, the skew is a maximum of one.

The skew calculation envelope is not symmetric in that a spectral peakclose to 300 Hz or close to 1800 Hz will have most of its neighborsabove or below the peak. Under these conditions, a distant signal peakmay have an undesirably strong effect on the skew measurement as definedby the trial discriminant. For this reason ramp weighting decreases theemphasis of the distant frequency peaks. The modified calculation ofspectral skew is as follows:SpecSkew=sqrt(sum(xprod(j))/xden)  [3]where:xprod(j)=(1−abs(j−PeakIndex))/(HiFilterindex−LowFilterindex))*SpecRatioj)*(j−PeakIndex)ˆ2)

(for j=low filter index to high filter index)

and:xden=(Normalization*PeakSpectralRatio)  [4]where:Normalization=sum((1−abs((j−PeakIndex))/(HiFilterIndex−LowFilterIndex))*(j−PeakIndex)ˆ2)

Testing of heart cycle signals containing clicks and bruits has revealedthat most bruits have a lower skew ratio while clicks usually have ahigher skew ratio. In one embodiment, a skew ratio rejection thresholdis utilized to distinguish clicks from bruits.

If both conditions are met in steps 5920 and 5922 (i.e., the currentpeak has a skew below the skew threshold just discussed and the currentpeak is a true frequency peak in the original spectrum), the currentbruit candidate under scrutiny is entered into the bruit candidate,table in a step 5924. In one embodiment, the heart beat count index, thespectral peak power, the skew ratio, and the time at the start of thespectrum slice are entered into the bruit candidate table. After thebruit candidate is entered into the bruit candidate table (or if eitherof the immediately preceding conditions is not met), a test is done at astep 5926 of whether there are more candidates to process for thecurrent spectrum slice. If so, the bruit candidate peak indices areupdated in a step 5928 and control passes to step 5916.

If there are no more spectral peaks to process for the current spectrum,a determination is then made at step 5930 of whether there are moreinitial bruit candidates to process for the systolic or diastolicinterval. If so, the bruit candidate indices are updated in a step 5932and control passes to step 5912. In one embodiment, if there are no morebruit candidates to process, the bruit candidate detection process shownin FIG. 60 is complete as shown in FIG. 59 to process the next heartbeat cycle until all parsed heart beat cycles have been processed.

Referring again to FIG. 59, after both the systolic and diastolicintervals have been processed in steps 5804 and 5806, the processingreturns to a step 5808, where all counters and indices are updated. Atstep 5810, a test is made of whether further heart beat cycle signalsneed to be processed. If so, the loop continues at step 5806, otherwisethe process completes.

A sample of the bruit candidate table for one heart waveform of apatient file is shown in FIG. 66. Note that a column for the value of abruit probability indicator (“mbProb”) has been initialized to allzeroes. This will be used in subsequent steps to store the valuescalculated for the bruit candidate probability indicators.

Once the bruit candidate table in FIG. 66 has been assembled and thereare no more heart cycle signals to process (as tested for in step 5810of FIG. 59), noise cancellation is performed. As discussed earlier, asecond channel can be used to provide a background noise signal. Thisbackground noise signal can be used to detect false bruit candidatesthat may actually have been caused by events external to the patient,such as fan hum, talking, etc. Referring back to FIG. 51, if backgroundnoise signal data is available (as tested in a step 5125), a separatebruit candidate table is generated in a step 5135 from the backgroundnoise signal to be used in the noise cancellation process. Thebackground noise bruit detection uses the same process, but a differentspectrum power and time data energy power threshold, as compared to thebruit detection used with the heart audio signals in the processdescribed above.

In one embodiment, noise cancellation is performed on the bruitcandidates as shown in step 5150 of FIG. 51 and described in furtherdetail with respect to FIG. 61. The noise cancellation process uses atwo-pass approach. As shown in a step 6002 of FIG. 60, the first noisecancellation pass compares the heart audio bruit candidate table to thebackground noise bruit candidate table. Each entry in the heart audiobruit candidate table is scanned in sequence with a subsequent scan ofthe background noise bruit candidate table. If a background noise bruitcandidate is detected that is close in peak frequency and in time to theheart audio bruit candidate, the heart audio bruit candidate iscancelled by replacing the skew ratio value with a high value near one.

FIG. 62 provides further detail on the first noise cancellation pass. Ina step 6102, noise cancellation parameters (derived from observations ofnoise induced bruits) are initialized. A loop is entered at a step 6104,wherein a heart audio bruit candidate is selected. In a step 6106, thebackground noise bruit candidates are scanned and a determination ismade in a step 6108 of whether the bruit candidate from the heart soundsignal was within one spectrum segment in time (that is, within 15milliseconds) of the background noise bruit candidate. This is themaximum time difference expected for events appearing in both channels.If so, then in a step 6110, the peak frequency of the heart audio bruitcandidate is compared to the peak frequency of the background noisebruit candidate. If the peak frequency separation is less than the noisecancel frequency separation threshold of 1200 Hz times the heart audiobruit candidate skew ratio, the current heart audio bruit candidate iscanceled in the bruit candidate table in a step 6112 by, for example,replacing the measured skew ratio with a high value near one. The highskew ratio value in an embodiment (i.e., close to the value one) willhave the effect of removing the bruit candidate from contributing to thecomputation of the probability discussed below. If the bruit candidatewas cancelled, a cancelled bruit counter is incremented in a step 6114.At a step 6116, a determination is made of whether there are any morebruit candidates to process. If so, control passes back up to step 6104.Otherwise, the first noise cancellation pass ends.

The second noise cancellation pass, illustrated in step 6004 of FIG. 60,examines the heart audio bruit candidate table only. Each entry isexamined for cancelled skew ratios. In an embodiment, if the skew ratiovalues indicate a cancelled bruit candidate, the adjacent entries in thetable are examined to see if either one should be cancelled as well. Ifan uncancelled bruit candidate is from a spectrum segment next to onethat was previously canceled and has a peak frequency within the peakfrequency separation threshold, it is cancelled. This could, forexample, be within a range of 400 Hz times 0.65, which represents anominal skew ratio.

FIG. 63 provides further detail on the second noise cancellation pass.In a step 6202, appropriate noise cancellation parameters areinitialized. A loop is entered at a step 6204, wherein a bruit candidateis selected. In a step 6206, a determination is made of whether theselected bruit candidate was cancelled in the first noise cancellationpass. If so, in a step 6208, each bruit candidate entry adjacent to thecanceled entry in the table is examined for three conditions. In a step6210, the adjacent candidate entry is examined to see if it has alreadybeen canceled. If yes, control passes to a step 6220. If not, then in astep 6212, the candidate entry is examined to determine if the candidateis from a spectrum segment next to the cancelled bruit candidate. Ifnot, control passes to a step 6220. If the entry is from an adjacentspectrum segment, then a test is performed in a step 6214 whether thepeak frequency of the adjacent candidate entry is close to the currentcancelled bruit candidate in frequency and time. If so, the adjacentcandidate entry is then cancelled a step 6216 by, for example, replacingthe measured skew ratio with a value close to one and a cancelled bruitcounter is incremented in a step 6218. A determination is then made in astep 6220 of whether there are any more bruit candidates to process. Ifso, control passes back up to step 6204. Otherwise, the second noisecancellation pass ends.

Processing Bruit Candidates

Referring back to FIG. 4, following the generation of the bruitcandidate table as part of step 3000 described above, the bruitcandidates are then processed at a step 4000 to determine the degree towhich a patient has repetitive bruits. The method of assigning aprobability of repetitive bruits causes each bruit candidate tocontribute in a cumulative process to the overall Flow Murmur Score.This contribution occurs since each bruit candidate will have aprobability associated with it that the bruit candidate is an actualbruit and, therefore, that the patient has CHD.

The important parameters associated with the development of aprobability indicator of coronary heart disease (Flow Murmur Score) arelisted below. A brief description of their purpose is included. The useof the parameters is explained further in subsequent text. NominalParameter Description Value Bruit/ClickThreshold The Skew Level forBruit/ 0.56 Click for 50 percent probability Click90PercntProbabilityThe Skew Level for 90 0.38 percent Click ConfidenceBruitSpectralRatioThreshold The SNR defining 50 18.5 dB percent BruitConfidence Bruit90PercntProbability The SNR defining 90 24.0 dB percentBruit Confidence BruitCutoffProbability SNR below this level is 14.00 dBignored BruitsPerRespirationCycle Expected number of Bruits 2.0 perRespiration Cycle VarianceFrequency Uncertainty in the Bruit 75 HzFrequency Measurement VarianceTime Uncertainty in the Bruit 20 ms TimeMeasurement ProbabilityCutoffThreshold Probability cutoff 0.09 threshold

The values of the skew and peak power (PkPwr) for each bruit candidateshown in the bruit candidate table in FIG. 66 comprise single values.Single values representative of energy distribution usually indicate thecentroid of that energy distribution, which represents the whole amountof the energy and the center point of that energy. For example, aFourier Transform analysis of a time waveform only analyzes frequenciesthat are related to the sampling rate and the number of frequenciesanalyzed (F_(i)=i·F_(samp)/N) as individual filters. If the timewaveform contains a signal that is exactly at one of these frequencies,then the energy will be just in the one filter, but if it is slightlyhigher in frequency, then the energy will be distributed over the twofilters, and so the centroid measurement helps refine the actualfrequency measurement further.

When the frequency of a waveform changes slightly during the collectioninterval, the energy will also be distributed over several filters. Inthis case it is better to consider the distribution of the energy ratherthan just the centroid of the energy. One could look at the total energyin the signal, and then plot the cumulative distribution contributed byall the filters, as seen in the two plots shown in FIG. 67. Widerspreading response 6610 in FIG. 67 has a longer slope than thinnerspreading response 6620, so the slope could be used as an indication ofthe degree of spread (i.e., if s denotes the slope, a calculation of{s=100%/spectrum size} could be used to determine the slope and,consequently, an approximation of the degree of spread).

In order to calculate a probability from the spectral measurements, aprobability function was designed in one embodiment that could be fit tothe measured parameters. The model selected for the probabilityfunction, (P), was the Fermi factor that was initially derived for theenergy distribution of charges in a conductor. The form of the functionis as follows:P(y)=exp(y)/(1+exp(y))  [5]

which has the values shown in Table 6: TABLE 6 Fermi function values yValue P −∞ 0/(1 + 0) 0.0 0 1/(1 + 1) 0.5 ∞ ∞/(1 + ∞) 1.0

Table 6 above shows that the peak value of the signal occurs at the 50%point on the accumulative energy curve, assuming that the spreading isbalanced. This means that a signal can be represented by its amplitude,frequency, and spreading factor, whereas a centroid could only give theamplitude and frequency. This same method can be used to typify a set ofvalues that spreads over a given range. As shown, the function has avalue of 0.5 for y equal to zero and rolls to either zero or one forincreasing or decreasing values of y. For purposes here, the probabilitythat an anomaly is likely to be a bruit will be a function of the SNR.

A second independent probability will be a function of the skewparameter. Considering SNR or Skew to be a value x, then y above will bedefined as:y=k*(x−x50)  [6]

where x50=the value of x where the probability is 0.5

and k=a constant which defines the slope of the probability function

This function rolls from zero through 0.5 at x50, to one, (or vice-versadepending on the sign of k), with a slope determined by the constant, k.The value of k controls the slope of the probability function. A sharpdiscriminant will switch from 0 to 1 with a small change in x. When thenumerator of the equation above (P(y)=exp(y)/(1+exp(y))) is 9, thefunction has a value of nine tenths corresponding to a 0.9 probability.Initial settings for k can be established by making a judgment as towhen a bruit could be asserted with 90 percent confidence. When thevalue of x is assigned as having a 0.9 probability (x90), then k can beevaluated yielding:k=log(9)/(x90−x50)  [7]where x90 and x50 can be estimated as discussed below.

FIG. 70 provides further detail on step 4000 in FIG. 4 of processing theidentified bruit candidates. In FIG. 70, an individual probabilityindicator is generated in step 6910 for each entry in the bruitcandidate table. As described above, the individual probabilityindicator referenced in step 6910 utilizes two independent probabilityfunctions to develop the probability that a spectral anomaly is a bruitcandidate. As each anomaly has a time position in diastole and a peakfrequency, a 2-dimensional probability function is built for each of thebruit candidates and thereafter assessed. As each heartbeat isprocessed, each bruit candidate listed in the bruit candidate table willbuild up the 2-dimensional probability indicator according to the SNR,diastolic time, frequency, and the skew characteristics of the bruitcandidate. In an embodiment, the skew threshold, where an anomaly wasequally likely to be a bruit or a Click was found to be very close to0.56. Thus a skew of 0.56 corresponded to x50 for the Click-bruitdiscriminant. An inspection of many detected anomalies revealed thatClicks and bruits can be effectively discriminated if the skew ratio waslower than the threshold value by 0.18. Hence x90 is set toapproximately 0.38, the value establishing the anomaly as a bruit with90 percent confidence. These parameters can be given slight adjustmentsto improve the probability results as patients with known heartconditions are processed.

From the values adopted above and using the Fermi equation discussedearlier, the probability that an anomaly is a bruit (not a click) isgiven by:P(Bruit/Click)=aterm/(1+aterm)  [8]

Where aterm=exp (A*(skew−0.56))

And A=log(9)/(0.38−0.56)

A second probability function can be defined to take into account theSNR at the spectral peak. Although a detection threshold close to 7.5 dBhas been used in listing anomalies, testing has shown that a power ratioclose to 18.5 dB corresponds to a 50 percent probability of being abruit. Further, it was estimated from experimental observations that ata SNR close to 24 dB, the anomaly was a bruit with 90 percent certainty.These values are used to evaluate a probability of an anomaly being abruit based upon the SNR.P(Bruit)=bterm/(1+bterm)  [9]

Where bterm=exp(B*(SNR−18.5))

And B=log(9)/(24−18.5)

In an embodiment, the signs of the terms A and B are opposite producinga bruit probability function which decreases for increasing Skew, butincreases with increasing SNR. FIG. 68 shows the values of an exampleprobability function over the operable SNR range with a threshold at 8.5dB and a 90 percent confidence level 4 dB above the threshold.

Since probability of a bruit and the probability of a click areindependent functions, then the probability that an anomaly is a bruitis simply the complement of the product of the two probabilities thatthe anomaly is not a bruit. The use of the product of probabilities of‘No Bruit’ has been used to consolidate the probability measurements.

As described above, the anomalies that are listed in the bruit candidatetable carry a peak frequency and a time stamp. The data from theheartbeat-parsing algorithm then makes it possible to specify when theanomaly occurs relative to S1 or S2 heartbeat pulses as desired.Plotting the values of the individual probability indicators for eachentry in the bruit candidate table would produce a figure such as thatshown in FIG. 69.

Since attention here is focused on diastole, a time relative to S2 ismost meaningful. Significant bruits are those which repeat themselves atnearly the same audio frequency and the same time within the diastolicperiod. To allow such repetitive bruits to build a strong probability,the probability indicator for each bruit can be expanded into a2-dimensional probability function with a time and a frequency axis.

In order to accurately plot the 2-dimensional probability plot for asingle anomaly, it is helpful to specify the character of the functionfor a single bruit candidate. If there were no uncertainty in the timeor the frequency measurement, a single resolution point could beassigned the probability calculated above. In reality, however, it isnot realistic to think that a ‘similar’ bruit will repeat its time andfrequency parameters exactly. Hence, it is helpful to specify anuncertainty in each dimension and extend the envelope of the probabilitymeasurement as a 2-dimensional envelope, such as a Gaussian envelope,decreasing in value as the distance from the measured position increasesin time and frequency.

In an embodiment, the time and frequency projections of the probabilityenvelopes for a measurement can take the form:GaussEnvelope=exp(−(((x−xo)/widthx50)ˆ2))  [10]

Where x=time or frequency

x0=the coordinate position of the anomaly

and widthx50=the displacement from x0 at which the function is at halfits peak

FIG. 71 provides further detail on step 6910 in FIG. 70 of generating anindividual probability indicator for each bruit candidate. In steps 7002through 7014 of FIG. 71 a number of parameters are computed andinitialized, all of which will be used in the bruit probabilitycomputation. In a step 7002, parameters for calculating the bruitprobability are initialized. In a step 7004, a bruits per respirationdecay component is computed for use later in the calculation of acovariance modifier. In a step 7006, values for time interval andfrequency spread uncertainty are computed as expressed in equation [8]and equation [9]. In steps 7008 and 7010, the one-dimensional andtwo-dimensional arrays for calculating the probability indicators areinitialized. In a step 7012, the probability function parameters for theskew ratio and bruit candidate peak power are calculated. In a step7014, the covariance modifier for the probability of bruits iscalculated. In a step 7016 of FIG. 70, a test is performed to determineif any bruit candidates exist in the bruit candidate table. If so, anindividual probability indicator for each bruit candidate is calculatedin a step 7018. If no bruit candidates exist, control passes to step5000, whereby a single probability indicator of 0 will be generated.

FIG. 72 provides further detail on the actual calculation process of anindividual probability indicator for each bruit as shown in step 7018 ofFIG. 70. At a step 7102, the number of the current heart cycle signal isdetermined, from which a heart cycle index into the bruit candidatetable is calculated in a step 7104. In a step 7116, a time index iscalculated from the start of the heart cycle index. As stated earlier,each bruit candidate in the bruit candidate table comprises two valuesfrom which an individual probability can be calculated—the skew ratioand the peak power. In a step 7118, a probability term is calculatedfrom the skew ratio. In a step 7120 a probability term is calculatedfrom the signal-to-noise ratio of the peak. In a step 7204, the twoprobability terms calculated from the skew ratio and the peak power arecombined to form a single bruit probability value. In an embodiment,this value is between zero and one.

Once the single bruit probability value has been determined and storedin step 7204, a test is then performed in a step 7206 of whether thatsingle bruit probability value is greater than a previously selectedprobability threshold. At a step 7206, a check is made of whether thebruit probability just calculated is greater than the predefined minimumprobability threshold. If so, the process of calculating the bruitprobability value for the current bruit candidate completes. If it isnot greater than the threshold, the single bruit probability value isset to a value of zero in a step 7208. A test is then performed at astep 7210 of whether further bruit candidates remain to be processed. Ifso, control passes back to a step 7116, otherwise the process completes.

Referring back to FIG. 70, in a step 6920, a calculation is made of theGaussian probability envelope in the time domain for bruit candidatesthat meet the bruit probability threshold. This calculation will producean array of values, with the number of values in the array beingdetermined by the average heartbeat period of the patient divided by thesample rate of the data being used (in this case the narrow band samplerate). In an embodiment, the probability values determined at this stepcorrespond to the probability that the bruit candidate is not indicativeof cardiovascular disease (i.e., a value of zero indicatescardiovascular disease, a value of one indicates no cardiovasculardisease). Thus, the array produced in step 6920 is referred to as aninverse time domain array. An example of such an array is shown in FIG.75.

In order to plot the data points of the Gaussian function shown in FIG.75, the values in the array are first subtracted from one, producingprobability values that correspond to the probability that the bruitcandidate is indicative of cardiovascular disease (i.e., a value of zeroindicates no cardiovascular disease, a value of one indicatescardiovascular disease). Plotting the resulting values produces awaveform with a smooth-topped mountain with a unit height at the anomalylocation. The two-dimensional projection of the Gaussian function in thetime domain is illustrated in FIG. 76.

Similarly, as shown in step 6930 of FIG. 70, calculation of the Gaussianprobability envelope in the frequency domain will produce an array ofvalues, with the number of values in the array in one embodiment equalto 64. In an embodiment, the probability values determined at this stepcorrespond to the probability that the bruit candidate is not indicativeof cardiovascular disease (i.e., a value of zero indicatescardiovascular disease, a value of one indicates no cardiovasculardisease). Thus, the array produced in step 6930 is referred to as aninverse frequency domain array. An example of such an array is shown inFIG. 77.

In order to plot the data points of the Gaussian function shown in FIG.77, the values in the array are first subtracted from one, producingprobability values that correspond to the probability that the bruitcandidate is indicative of cardiovascular disease (i.e., a value of zeroindicates no cardiovascular disease, a value of one indicatescardiovascular disease). Plotting the resulting values produces awaveform with a smooth-topped mountain with a unit height at the anomalylocation. The two-dimensional projection of the Gaussian function in thefrequency domain is illustrated in FIG. 78.

As specified in step 6940 of FIG. 70, the expansion into the2-dimensional probability of a single bruit is calculated as the vectorproduct of the Gaussian envelopes in frequency and time all scaled bythe probability that the anomaly is a bruit as calculated from SNR andskew as described above. The vector product of a one-dimensionalprojection of a Gaussian function in the time domain (such as in FIG.76) and a one-dimensional projection of a Gaussian function in thefrequency domain (such as in FIG. 78) results in a two-dimensionalmatrix, an empty example of which is shown in FIG. 79. As just oneexample, a bruit candidate based on the values shown in FIG. 75 and inFIG. 77 that only has a peak and one value at each location away fromthe peak might take on values that only populate the entries that havebeen shaded in FIG. 80. The center shaded entry could represent the peakand each of the perimeter entries could represent the result of theGaussian distribution. A three dimensional plot of the matrix in FIG.80, with an indication on the time axis of S1 and S2, is shown in FIG.81 (not drawn to scale).

The flow chart in FIG. 73 provides further detail of the process shownin step 6940 of FIG. 69, in which the two-dimensional Gaussiandistribution for each entry in the bruit candidate table is calculated.At a step 7302, the values of a weighted probability function along thetime axis are computed. In step 7304, the two-dimensional probabilitycontribution for the current bruit is calculated by calculating an outerproduct of the frequency domain Gaussian distribution array and the timeaxis weighted probability function. In step 7306, the covariancemodifier is applied to the individual two-dimensional probabilitycontribution to account for the effects of respiration. In a step 7308of FIG. 73, the two-dimensional running total bruit matrix is updated.

As each individual two-dimensional bruit Gaussian distribution matrix iscalculated, its effects on the overall probability indicator (i.e., FlowMurmur Score) are accumulated by performing a dot product of the inverseof the Gaussian distribution envelope with a two-dimensional runningtotal bruit matrix, which represents the current running total of theaccumulated bruit probabilities for each time and frequency component ofthe heart cycle signals in a given heart waveform. Hence, if the firstbruit candidate in the bruit candidate table corresponds to the matrixof FIG. 80, then the two-dimensional running total bruit matrix will beidentical to the matrix of FIG. 80 until the second bruit candidate inthe bruit candidate table is processed. For a given waveform, thetwo-dimensional running total bruit matrix is initially initialized toall ones (this essentially represents the probability of no bruits for agiven bruit candidate) so that the initial matrix multiplications do notpropagate zeroes.

Plotting the results of one exemplary bruit Gaussian distribution for asecond bruit candidate will take the form of the two-dimensional bruitGaussian distribution matrix shown in FIG. 82. After the first bruitcandidate is processed as just described, the two-dimensional bruitGaussian distribution matrix of the second bruit candidate is invertedand then multiplied by the two-dimensional running total bruit matrix toobtain an updated two-dimensional running total bruit matrix as shown inFIG. 83. The cross-hatch section, labeled 51 a illustrates the time andfrequency overlap of the Gaussian bruit distributions of the two bruitcandidates. In three dimensions, the overlapping phenomenon betweenadjacent bruits could produce the figure shown in FIG. 84.

The above process of calculating two-dimensional bruit Gaussiandistribution matrices is repeated for each bruit candidate within agiven heart cycle and then for each bruit candidate in subsequent heartcycles until the entire heart waveform signal has been processed toproduce a completed two-dimensional running total bruit probabilitymatrix for a given heart waveform. The process is then completed foreach of the heart waveform signals to produce nine separate completedtwo-dimensional running total bruit probability matrices for each of therespective nine heart waveform signals in the illustrated embodiment. Aswill be appreciated, the overlapping of the bruit candidates in time andfrequency is emphasized by the multiplication of the matrices, which inturn contributes to the calculation of the likelihood of the patienthaving coronary heart disease. That is, when bruit candidates fallwithin the same time and frequency windows within one heart cycle orwithin different heart cycles, this is viewed as increasing thelikelihood that the patient has coronary heart disease and theembodiments of the invention emphasize this in the above-describedmanner, which is ultimately reflected in the later generated probabilityindicator of coronary heart disease for each individual heart waveformand in the overall probability indicator of coronary heart disease forall the waveforms.

In summary, initial probability data on each bruit candidate is mappedin the two-dimensional bruit candidate matrix. The relative time of theanomaly in the bruit candidate in each bruit candidate heartbeat is onone axis of the matrix while the frequency of the signal maximum is onthe other axis of the matrix. Each bruit candidate is spread over anarrow time and frequency region using a two-dimensional Gaussian wavefunction, which may be plotted in three dimensions, with peakprobability equal to the calculated probability indicator of the bruitcandidate. The dimensions of the Gaussian wave in time and frequencyrepresent regions of uncertainty associated with the respectivemeasurements. This function is then inverted and vector multiplied bythe running total bruit matrix for all bruit candidates in a given heartwaveform. The matrix data of the two-dimensional bruit Gaussiandistribution array and the two-dimensional running total bruit matrixare maintained as probability of bruit so that the completedtwo-dimensional running total bruit matrix may be collapsed to a singlenumber, as described below, which represents the probability of no bruitfor a given waveform and thus the probability of no coronary heartdisease for the given waveform. By subtracting the final complementationfrom one (1−P[NB]), the probability is returned to that of repetitivebruits. FIG. 85 illustrates a grayscale map representation of thetwo-dimensional probability of repetitive bruits for the heart-audiofile example carried throughout this algorithm description.

As discussed above, each anomaly logged as a bruit candidate isevaluated in a statistical manner and combined in a summary probabilitycalculation. Since the operative search here is for repetitive bruits,the process considers the peak audio frequency of the bruit as well asthe relative time of occurrence of the bruit in the diastolic interval.The algorithm described above includes the accumulation of all bruitcandidates in a time-frequency probability function. Independent bruitcandidate events are then consolidated into a repetitive bruitprobability as a function of frequency that is then further consolidatedinto a single repetitive bruit probability value for a single patientfile.

Further, and as also described above, two additional processing stepsproduce a probability of repetitive bruits that applies to one heartwaveform of a patient file. The first step is a consolidation viamultiplication of each of the probability indicators of the completedtwo dimensional running total matrix along the time domain axis for eachfrequency index. The one-dimensional grayscale plot labeled 8820 on theright hand side of FIG. 86 shows the results of this firstconsolidation.

The consolidation across the time domain axis is followed by aconsolidation via multiplication of each of the probability indicatorsacross the frequency domain axis into a probability indicator ofcoronary heart disease for the given heart sound signal, as shown instep 5000 of FIG. 2. The flow chart in FIG. 74, along with thediscussion below, provides further details on this consolidationprocess. At a step 5002, parameters associated with the consolidationprocess that will generate a single value probability indicator areinitialized. At a step 5004, a new current product is calculated bymultiplying the old current product value by the probability of nobruits for the current spectral index. At a step 5006 a check isperformed of whether there are further spectral component probabilitiesto process. If so, the spectral index is updated in a step 5008 andcontrol then passes to step 5004. If there are no further spectralcomponent probabilities to process, a probability of bruits iscalculated in a step 5010 by subtracting the single resulting value(corresponding to the probability of no bruits) from one.

The single probability indicator of bruits (corresponding to theprobability of coronary heart disease) for the given waveform of thefinal file consolidation is reported by the number designated as 8810 inthe upper left hand corner of the main plot in FIG. 86. This probabilityindicator of coronary heart disease is repeated for each given heartwaveform.

The intent of the first consolidation described above is to combine timedata across diastole at each frequency in a manner such that a highlevel of confidence could be placed on a final probability at each audiofrequency. This has required that the initial probability of a bruitmeasurement for each time cell had to be reduced in scale by somefactor. The factor for achieving this confidence was based upon theexpected repetitive nature of serious bruits. A criterion wasestablished so that bruits must be recurring through the audio recordingat some predefined rate. It must be noted that the choice of parametershas been guided by the angiography data from a known patient set. Anarbitrary, but logical, choice was to expect the bruits to recur inpairs at a nominal respiration rate, that is, every five seconds. Inorder to derive a scale factor for the first consolidation, it wasassumed that a sequence of anomalies at one frequency, each with 50percent probability of being a bruit and occurring twice every fiveseconds, should consolidate into a single probability also equal to 0.5.The basic consolidation of the probability data is a calculation byproducts of the probability of No bruit, given the events that have beendetected. This is the product of the No bruit probabilities for eachfrequency across the time line. The time line is windowed to encompassapproximately 600 milliseconds after the onset of S2. Hence theconsolidation of our adjusted hypothetical bruits occurring with 50percent probability is given by the expression:P′(NB)=(1−alpha*0.5)ˆBperR=0.5[Adjusted Probability]  [11]

where

BperR=2*RecordingTime/5; [Bruits per Recording]

Solving for Alpha, we have:Alpha=(1−10ˆ(log 10(0.5)/BperR))/0.5[Modifier for Prob(Bruit)]  [12]

The following equation, (C4), has been used to calculate a probabilityof repetitive bruits as a function of frequency.P′(NB)=PRODUCTS of (1−alpha*P(ti)) for independent ti  [13]

The time indices (ti), of the product terms are just far enough apart tobe independent. Recalling that a Gaussian envelope represented theprobability function for each anomaly, the separation for independenceis a function of the slope of the Gaussian envelope set by itshalf-width. Recall that this calculation is the probability of Nobruits. Given:GaussEnvelope=exp(−(((x−xo)/widthx50)ˆ2))  [14]thendelta_(—) t=1.69*widthx50[the separation for independence]  [15]

Although any one set of points on the probability distribution separatedby delta_t can be multiplied together to produce a consolidatedprobability, the resultant value will fluctuate according to theparticular set selected. A better result is obtained by using theaverage of all the discrete sets that have delta_t separation. Once theaverages have been calculated for all discrete filter frequencies, thetime variable has been eliminated and a consolidated probability ofrepetitive bruits as a function of frequency has been realized.

Since appropriately separated frequency probabilities can be consideredindependent measurements, they can be consolidated in a secondconsolidation using equation (C4) with an Alpha substituted by Beta asset forth below. However, repetitive bruits at 300 Hz do not carry thesame level of significance as those of higher frequency. This is becausemore constricted flow will produce stronger turbulence and associatedhigher frequencies. For this reason, a weighting factor has beenarbitrarily assigned that lowers the associated bruit probability forthe lower frequency. This weighting function is given by the expression:Beta(Frequency)=min{1,sqrt(Frequency/1000)}  [16]

The square root function causes the weight to increase rapidly from 0.5at 300 Hz to 0.84 at 700 Hz. The value is limited to one for frequenciesabove 1000 Hz. Alpha in equation (C4) is replaced with Beta toconsolidate the frequency data into a single probability of repetitivebruits for the file. The terms are weighted by increasing frequency toaccentuate the contributions of the higher frequencies. As in theconsolidation across the time axis, all available sets of measurementswith independent separations of 1.69 times the half-frequency width ofthe Gaussian envelope are averaged. The result is a single probabilityof repetitive bruits for one file. The results of this probabilitycalculation are displayed in the upper left hand corner of each2-dimensional probability plot.

Finally, a third consolidation process combines the multiple filesummaries into one patient summary for a file set, usually nine audiorecordings from sites positioned in a 3×3 array on the chest over theheart. The probability of repetitive bruits measure for each of the ninerecording sites must be consolidated into a single Flow Murmur Score forthe patient. Based on current evidence, there is no clear basis forassuming that the data in the audio from neighboring chest locations isindependent. There is evidence in the summary patient plots that soundsfrom a common source appear in audio recordings taken from adjacentpositions. The individual file probabilities are presumed covariant andhave been consolidated using a method similar to equation (C4) with anAlpha of 0.5.

Given a bruit Source that can be equally heard from two sites, then theconstraint of the calculation is that the cumulative probability fromthe two recording sites match either one individually. This implies thatsome scale factor, a, can be applied to yield the desired result.(1−a*P1(NB))*(1−a*P2(NB))=1−P(NB), with P=P1=P2,(NB)−>No bruit  [17]Then solving for a*P(NB):a*P(NB)=sqrt(P(NB))  [18]

The desired result merely requires taking the square root of theprobabilities of no bruit, which results in an even simpler calculationthat produced results very similar to previously used methods. However,the new approach provided more separation in results between normal anddiseased patients. A slightly different but useful calculation of acomposite probability can be obtained from the product of the square ofthe individual probabilities of bruits.

Using the methodology described above, a differential analysis wasundertaken to determine whether the methodology could discriminatebetween various degrees of coronary artery lesions. For twenty-twopatients undergoing a percutaneous coronary intervention, FMS scores(i.e., overall probability indicators) were computed both before andafter the intervention. A statistically significant decrease in FMSoccurred after intervention (p=0.02), indicating that the methodologyindeed found fewer bruits after the coronary artery lesion was reduced.

Set forth in detail above are aspects of at least one embodiment of theinvention. Each of the features set forth above may be implemented inone system, method, and/or computer executable code in accordance withan embodiment of the invention. Alternatively, each of the features setforth above may be separately implemented in different systems, methods,and/or computer executable codes in accordance with embodiments of theinvention.

Furthermore, the principles, preferred embodiments, and modes ofoperation of the invention have been described in the foregoingdescription. However, the invention that is intended to be protected isnot to be construed as limited to the particular embodiments disclosed.Further, the embodiments described herein are to be regarded asillustrative rather than restrictive. Others may make variations andchanges, and equivalents employed, without departing from the spirit ofthe invention. Accordingly, it is expressly intended that all suchvariations, changes and equivalents which fall within the spirit andscope of the invention as defined in the foregoing claims be embracedthereby.

1. A method comprising: receiving cardiovascular sound signals of apatient that were previously captured at a point of care of the patient;processing at a location remote from the point of care the receivedcardiovascular sound signals to generate a probability indicatorindicative of the likelihood that the patient has cardiovasculardisease; and forwarding the probability indicator to at least one of thepoint of care and another location.
 2. The method of claim 1, thereceived cardiovascular sound signals further comprising digital signalsthat were previously converted from analog signals.
 3. The method ofclaim 1, the received cardiovascular sound signals further comprising aplurality of heart waveform signals each corresponding to a differentlocation where the patient's heart sounds were sensed.
 4. The method ofclaim 3, each heart waveform signal further comprising a plurality ofheart cycle signals.
 5. The method of claim 4, each heart cycle signalcorresponding to a heart cycle of the patient.
 6. The method of claim 1,said receiving further comprising receiving a plurality of data files,each data file containing at least one heart waveform signal of apatient.
 7. The method of claim 6, each of said data files alsoincluding background noise signals.
 8. The method of claim 8, each ofsaid data files also including an ECG signal.
 9. The method of claim 1,said forwarding further comprising forwarding the generated probabilityto a location remote from a location where the probability indicator wasgenerated.
 10. The method of claim 9, further comprising forwarding theprobability indicator to the point of care over a data communicationsnetwork
 11. The method of claim 10, wherein said data communicationsnetwork further comprises the internet.
 12. The method of claim 1, saidreceiving further comprising receiving the cardiovascular sound signalsin an encrypted format.
 13. A system comprising: means for receivingcardiovascular sound signals of a patient that were previously capturedat a point of care of the patient; means for processing at a locationremote from the point of care the received cardiovascular sound signalsto generate a probability indicator indicative of the likelihood thatthe patient has cardiovascular disease; and means for forwarding theprobability indicator to at least one of the point of care and anotherlocation.
 14. A computer readable medium containing computer programinstructions for: receiving cardiovascular sound signals of a patientthat were previously captured at a point of care of the patient;processing at a location remote from the point of care the receivedcardiovascular sound signals to generate a probability indicatorindicative of the likelihood that the patient has cardiovasculardisease; and forwarding the probability indicator to at least one of thepoint of care and another location.
 15. A method comprising: capturingcardiovascular sound signals of a patient at a point of care of thepatient; forwarding to a location remote from the point of care thecaptured cardiovascular sound signals; and receiving from the locationremote from the point of care a probability indicator indicative of thelikelihood that the patient has cardiovascular disease, the probabilityindicator being generated based on the cardiovascular sound signals thatwere forwarded to the location remote from the point of care.
 16. Themethod of claim 15, the captured cardiovascular sound signals furthercomprising a plurality of heart waveform signals each corresponding to adifferent location where the patient's heart sounds were sensed.
 17. Themethod of claim 16, each heart waveform signal further comprising heartcycles signals each corresponding to a heart cycle.
 18. The method ofclaim 15, further comprising capturing background noise signals andforwarding said background noise signals to the location remote from thepoint of care.
 19. The method of claim 15, further comprising capturingan ECG signal and forwarding said ECG signal to the location remote fromthe point of care.
 20. The method of claim 15, further comprisingencrypting the cardiovascular sound signals prior to said forwarding tothe location remote from the point of care.
 21. A system comprising:means for capturing cardiovascular sound signals of a patient at a pointof care of the patient; means for forwarding to a location remote fromthe point of care the captured cardiovascular sound signals; and meansfor receiving from the location remote from the point of care aprobability indicator indicative of the likelihood that the patient hascardiovascular disease, the probability indicator being generated basedon the cardiovascular sound signals that were forwarded to the locationremote from the point of care.
 22. A computer readable medium containingcomputer program instructions for: capturing cardiovascular soundsignals of a patient at a point of care of the patient; forwarding to alocation remote from the point of care the captured cardiovascular soundsignals; and receiving from the location remote from the point of care aprobability indicator indicative of the likelihood that the patient hascardiovascular disease, the probability indicator being generated basedon the cardiovascular sound signals that were forwarded to the locationremote from the point of care.